Equipment & supplies Medicaid rates by code
2,327 equipment & supplies codes with published Medicaid rates in five or more states. Each page compares every state's rate, unit and managed-care rule.
| Code | Service | States | Median rate |
|---|---|---|---|
| A4206 | Syringe with needle, sterile, 1 cc or less, each | 18 | $0.275 |
| A4207 | Syringe with needle, sterile 2 cc, each | 19 | $0.29 |
| A4208 | Syringe with needle, sterile 3 cc, each | 19 | $0.27 |
| A4209 | Syringe with needle, sterile 5 cc or greater, each | 18 | $0.34 |
| A4210 | Needle-free injection device, each | 10 | $3.24 |
| A4211 | Supplies for self-administered injections | 5 | $0.51 |
| A4212 | Non-coring needle or stylet with or without catheter | 14 | $4.47 |
| A4213 | Syringe, sterile, 20 cc or greater, each | 19 | $0.74 |
| A4215 | Needle, sterile, any size, each | 17 | $0.18 |
| A4216 | Sterile water, saline and/or dextrose, diluent/flush, 10 ml | 17 | $0.43 |
| A4217 | Sterile water/saline, 500 ml | 20 | $3.06 |
| A4218 | Sterile saline or water, metered dose dispenser, 10 ml | 5 | $0.57 |
| A4220 | Refill kit for implantable infusion pump | 9 | $39.95 |
| A4221 | Supplies for maintenance of non-insulin drug infusion... | 17 | $20.79 |
| A4222 | Infusion supplies for external drug infusion pump | 18 | $39.72 |
| A4223 | Infusion supplies not used with external infusion pump | 11 | $15.00 |
| A4224 | Supplies for maintenance of insulin infusion catheter | 18 | $23.26 |
| A4225 | Supplies for external insulin infusion pump | 15 | $2.95 |
| A4230 | Infusion set for external insulin pump | 17 | $12.68 |
| A4231 | Infusion set for external insulin pump, needle type | 15 | $6.93 |
| A4232 | Syringe with needle for external insulin pump, sterile, 3 cc | 16 | $3.13 |
| A4233 | Replacement battery, alkaline (other than j cell) | 16 | $0.63 |
| A4234 | Replacement battery, alkaline, j cell | 17 | $2.47 |
| A4235 | Replacement battery, lithium | 17 | $1.29 |
| A4236 | Replacement battery, silver oxide | 16 | $1.20 |
| A4238 | Supply allowance for adjunctive | 17 | $261.95 |
| A4239 | Supply allowance for non-adjunctive | 16 | $241.15 |
| A4244 | Alcohol or peroxide, per pint | 17 | $0.99 |
| A4245 | Alcohol wipes, per box | 17 | $2.13 |
| A4246 | Betadine or phisohex solution, per pint | 17 | $5.20 |
| A4247 | Betadine or iodine swabs/wipes, per box | 16 | $7.75 |
| A4248 | Chlorhexidine containing antiseptic, 1 ml | 6 | $0.13 |
| A4250 | Urine test or reagent strips or tablets | 14 | $17.01 |
| A4253 | Blood glucose test or reagent strips for home blood glucose... | 17 | $8.94 |
| A4255 | Platforms for home blood glucose monitor, 50 per box | 9 | $5.12 |
| A4256 | Normal, low and high calibrator solution / chips | 13 | $3.62 |
| A4257 | Replacement lens shield cartridge for use with laser skin... | 5 | $17.83 |
| A4258 | Spring-powered device for lancet, each | 14 | $2.12 |
| A4259 | Lancets, per box of 100 | 16 | $1.52 |
| A4261 | Cervical cap for contraceptive use | 8 | $60.59 |
| A4264 | Permanent implantable contraceptive intratubal occlusion... | 5 | $1,400.00 |
| A4265 | Paraffin, per pound | 15 | $3.56 |
| A4266 | Diaphragm for contraceptive use | 12 | $31.57 |
| A4267 | Contraceptive supply, condom, male, each | 17 | $0.40 |
| A4268 | Contraceptive supply, condom, female, each | 16 | $2.97 |
| A4269 | Contraceptive supply, spermicide (e.g., foam, gel), each | 11 | $9.28 |
| A4271 | Integrated lancing and blood sample testing cartridges for... | 9 | $30.69 |
| A4280 | Adhesive skin support attachment for use with external... | 14 | $5.83 |
| A4281 | Tubing for breast pump, replacement | 9 | $4.75 |
| A4282 | Adapter for breast pump, replacement | 9 | $7.49 |
| A4283 | Cap for breast pump bottle, replacement | 9 | $1.59 |
| A4284 | Breast shield and splash protector for use with breast pump | 9 | $8.85 |
| A4285 | Polycarbonate bottle for use with breast pump, replacement | 9 | $4.16 |
| A4286 | Locking ring for breast pump, replacement | 8 | $2.37 |
| A4287 | Disposable collection and storage bag for breast milk | 10 | $0.235 |
| A4295 | Intermittent urinary catheter; straight tip | 16 | $2.23 |
| A4296 | Intermittent urinary catheter; coude (curved) tip | 16 | $7.78 |
| A4297 | Intermittent urinary catheter; hydrophilic coating | 15 | $8.97 |
| A4300 | Implantable access catheter, (e.g., venous, arterial | 6 | $8.92 |
| A4305 | Disposable drug delivery system | 8 | $15.62 |
| A4306 | Disposable drug delivery system | 9 | $19.79 |
| A4310 | Insertion tray without drainage bag and without catheter | 21 | $7.13 |
| A4311 | Insertion tray without drainage bag with indwelling... | 20 | $13.05 |
| A4312 | Insertion tray without drainage bag with indwelling... | 19 | $16.35 |
| A4313 | Insertion tray without drainage bag with indwelling... | 18 | $18.19 |
| A4314 | Insertion tray with drainage bag with indwelling catheter | 21 | $24.05 |
| A4315 | Insertion tray with drainage bag with indwelling catheter | 20 | $25.43 |
| A4316 | Insertion tray with drainage bag with indwelling catheter | 18 | $28.12 |
| A4318 | Female external urinary collection cup | 7 | $7.57 |
| A4320 | Irrigation tray with bulb or piston syringe, any purpose | 21 | $5.01 |
| A4322 | Irrigation syringe, bulb or piston, each | 21 | $2.95 |
| A4326 | Male external catheter with integral collection chamber | 18 | $10.32 |
| A4327 | Female external urinary collection device; meatal cup, each | 16 | $43.72 |
| A4328 | Female external urinary collection device; pouch, each | 19 | $10.41 |
| A4330 | Perianal fecal collection pouch with adhesive, each | 15 | $7.15 |
| A4331 | Extension drainage tubing, any type, any length | 20 | $3.11 |
| A4332 | Lubricant, individual sterile packet, each | 18 | $0.125 |
| A4333 | Urinary catheter anchoring device, adhesive skin attachment | 20 | $2.31 |
| A4334 | Urinary catheter anchoring device, leg strap, each | 17 | $5.08 |
| A4335 | Incontinence supply; miscellaneous | 9 | $1.89 |
| A4336 | Incontinence supply, urethral insert, any type, each | 7 | $1.67 |
| A4338 | Indwelling catheter; foley type, two-way latex with coating | 20 | $11.15 |
| A4340 | Indwelling catheter; specialty type, (e.g., coude, mushroom | 20 | $28.87 |
| A4341 | Indwelling intraurethral drainage device with valve | 6 | $297.99 |
| A4342 | Accessories for patient inserted indwelling intraurethral... | 6 | $752.41 |
| A4344 | Indwelling catheter, foley type, two-way | 20 | $13.44 |
| A4346 | Indwelling catheter; foley type | 17 | $17.00 |
| A4349 | Male external catheter, with or without adhesive | 21 | $2.02 |
| A4351 | Intermittent urinary catheter; straight tip | 21 | $1.72 |
| A4352 | Intermittent urinary catheter; coude (curved) tip | 21 | $6.12 |
| A4353 | Intermittent urinary catheter, with insertion supplies | 21 | $7.30 |
| A4354 | Insertion tray with drainage bag but without catheter | 20 | $10.98 |
| A4355 | Irrigation tubing set for continuous bladder irrigation... | 17 | $8.91 |
| A4356 | External urethral clamp or compression device | 18 | $41.46 |
| A4357 | Bedside drainage bag, day or night | 20 | $9.40 |
| A4358 | Urinary drainage bag, leg or abdomen, vinyl | 20 | $6.31 |
| A4360 | Disposable external urethral clamp or compression device | 11 | $0.48 |
| A4361 | Ostomy faceplate, each | 20 | $17.76 |
| A4362 | Skin barrier; solid, 4 x 4 or equivalent; each | 21 | $3.43 |
| A4363 | Ostomy clamp, any type, replacement only, each | 19 | $2.50 |
| A4364 | Adhesive, liquid or equal, any type, per oz | 21 | $2.84 |
| A4366 | Ostomy vent, any type, each | 17 | $1.41 |
| A4367 | Ostomy belt, each | 21 | $7.30 |
| A4368 | Ostomy filter, any type, each | 18 | $0.275 |
| A4369 | Ostomy skin barrier, liquid (spray, brush, etc.), per oz | 21 | $2.30 |
| A4371 | Ostomy skin barrier, powder, per oz | 21 | $3.83 |
| A4372 | Ostomy skin barrier, solid 4 x 4 or equivalent | 20 | $4.21 |
| A4373 | Ostomy skin barrier, with flange (solid | 21 | $6.26 |
| A4375 | Ostomy pouch, drainable, with faceplate attached, plastic | 20 | $17.41 |
| A4376 | Ostomy pouch, drainable, with faceplate attached, rubber | 20 | $46.82 |
| A4377 | Ostomy pouch, drainable, for use on faceplate, plastic, each | 20 | $4.35 |
| A4378 | Ostomy pouch, drainable, for use on faceplate, rubber, each | 20 | $30.12 |
| A4379 | Ostomy pouch, urinary, with faceplate attached, plastic | 20 | $15.22 |
| A4380 | Ostomy pouch, urinary, with faceplate attached, rubber, each | 19 | $36.21 |
| A4381 | Ostomy pouch, urinary, for use on faceplate, plastic, each | 20 | $4.53 |
| A4382 | Ostomy pouch, urinary, for use on faceplate, heavy plastic | 20 | $23.68 |
| A4383 | Ostomy pouch, urinary, for use on faceplate, rubber, each | 20 | $27.74 |
| A4384 | Ostomy faceplate equivalent, silicone ring, each | 19 | $9.58 |
| A4385 | Ostomy skin barrier, solid 4 x 4 or equivalent | 21 | $5.08 |
| A4387 | Ostomy pouch, closed, with barrier attached | 19 | $2.79 |
| A4388 | Ostomy pouch, drainable | 21 | $4.35 |
| A4389 | Ostomy pouch, drainable, with barrier attached | 21 | $5.93 |
| A4390 | Ostomy pouch, drainable | 21 | $9.12 |
| A4391 | Ostomy pouch, urinary, with extended wear barrier attached | 21 | $6.81 |
| A4392 | Ostomy pouch, urinary, with standard wear barrier attached | 21 | $7.94 |
| A4393 | Ostomy pouch, urinary, with extended wear barrier attached | 21 | $8.77 |
| A4394 | Ostomy deodorant, with or without lubricant | 20 | $2.62 |
| A4395 | Medical supplies | 20 | $0.045 |
| A4396 | Ostomy belt with peristomal hernia support | 18 | $41.23 |
| A4397 | Irrigation supply; sleeve, each | 8 | $4.20 |
| A4398 | Ostomy irrigation supply; bag, each | 20 | $14.21 |
| A4399 | Ostomy irrigation supply; cone/catheter | 20 | $12.03 |
| A4400 | Ostomy irrigation set | 19 | $42.74 |
| A4402 | Lubricant, per ounce | 21 | $1.52 |
| A4404 | Ostomy ring, each | 21 | $1.55 |
| A4405 | Ostomy skin barrier, non-pectin based, paste, per ounce | 21 | $3.52 |
| A4406 | Ostomy skin barrier, pectin-based, paste, per ounce | 21 | $6.02 |
| A4407 | Ostomy skin barrier, with flange (solid, flexible | 21 | $8.74 |
| A4408 | Ostomy skin barrier, with flange (solid | 21 | $9.85 |
| A4409 | Ostomy skin barrier, with flange (solid | 21 | $6.40 |
| A4410 | Ostomy skin barrier, with flange (solid | 21 | $8.86 |
| A4411 | Ostomy skin barrier, solid 4 x 4 or equivalent | 20 | $5.15 |
| A4412 | Ostomy pouch, drainable, high output | 21 | $2.84 |
| A4413 | Ostomy pouch, drainable, high output | 20 | $5.58 |
| A4414 | Ostomy skin barrier, with flange (solid | 21 | $4.91 |
| A4415 | Ostomy skin barrier, with flange (solid | 21 | $5.99 |
| A4416 | Ostomy pouch, closed, with barrier attached, with filter | 21 | $2.75 |
| A4417 | Ostomy pouch, closed, with barrier attached | 21 | $3.83 |
| A4418 | Ostomy pouch, closed; without barrier attached, with filter | 20 | $1.84 |
| A4419 | Ostomy pouch, closed | 21 | $1.74 |
| A4420 | Ostomy pouch, closed | 11 | $1.39 |
| A4421 | Ostomy supply; miscellaneous | 6 | $4.48 |
| A4422 | Ostomy absorbent material | 18 | $0.13 |
| A4423 | Ostomy pouch, closed | 21 | $1.86 |
| A4424 | Ostomy pouch, drainable, with barrier attached, with filter | 21 | $4.75 |
| A4425 | Ostomy pouch, drainable | 21 | $3.57 |
| A4426 | Ostomy pouch, drainable | 21 | $2.65 |
| A4427 | Ostomy pouch, drainable | 21 | $2.78 |
| A4428 | Ostomy pouch, urinary, with extended wear barrier attached | 20 | $6.82 |
| A4429 | Ostomy pouch, urinary, with barrier attached | 20 | $8.56 |
| A4430 | Ostomy pouch, urinary, with extended wear barrier attached | 20 | $8.83 |
| A4431 | Ostomy pouch, urinary; with barrier attached | 19 | $6.51 |
| A4432 | Ostomy pouch, urinary | 21 | $3.69 |
| A4433 | Ostomy pouch, urinary | 21 | $3.44 |
| A4434 | Ostomy pouch, urinary | 20 | $3.86 |
| A4435 | Ostomy pouch, drainable, high output | 16 | $6.26 |
| A4436 | Irrigation supply; sleeve, reusable, per month | 16 | $19.05 |
| A4437 | Irrigation supply; sleeve, disposable, per month | 16 | $19.05 |
| A4438 | Adhesive clip applied to the skin to secure external... | 8 | $1.95 |
| A4450 | Tape, non-waterproof, per 18 square inches | 21 | $0.09 |
| A4452 | Tape, waterproof, per 18 square inches | 21 | $0.38 |
| A4453 | Rectal catheter with or without balloon | 11 | $19.00 |
| A4455 | Adhesive remover or solvent (for tape | 21 | $1.40 |
| A4456 | Adhesive remover, wipes, any type, each | 18 | $0.26 |
| A4458 | Medical supplies | 8 | $4.19 |
| A4459 | Manual transanal irrigation system | 11 | $180.00 |
| A4461 | Surgical dressing holder, non-reusable, each | 13 | $3.83 |
| A4463 | Surgical dressing holder, reusable, each | 13 | $15.44 |
| A4465 | Non-elastic binder for extremity | 6 | $11.38 |
| A4479 | Electronic transanal irrigation system | 6 | $653.40 |
| A4481 | Medical supplies | 17 | $0.42 |
| A4483 | Moisture exchanger, disposable | 12 | $4.14 |
| A4490 | Surgical stockings above knee length, each | 11 | $14.78 |
| A4495 | Surgical stockings thigh length, each | 15 | $20.11 |
| A4500 | Surgical stockings below knee length, each | 16 | $14.88 |
| A4510 | Surgical stockings full length, each | 13 | $19.81 |
| A4541 | Monthly supplies for use of device coded at e0733 | 6 | $31.83 |
| A4542 | Supplies and accessories for external upper limb tremor... | 5 | $413.21 |
| A4544 | Electrode for external lower extremity nerve stimulator for... | 8 | $5.02 |
| A4545 | Supplies and accessories for external tibial nerve... | 7 | $31.37 |
| A4550 | Surgical trays | 8 | $15.02 |
| A4554 | Disposable underpads, all sizes | 12 | $0.345 |
| A4556 | Electrodes, (e.g., apnea monitor), per pair | 18 | $11.76 |
| A4557 | Lead wires, (e.g., apnea monitor), per pair | 18 | $16.01 |
| A4558 | Conductive gel or paste, for use with electrical device | 16 | $5.53 |
| A4561 | Pessary, reusable, rubber, any type | 17 | $23.14 |
| A4562 | Pessary, reusable, non rubber, any type | 16 | $53.60 |
| A4563 | Rectal control system for vaginal insertion | 5 | $1,148.21 |
| A4565 | Slings | 17 | $8.93 |
| A4570 | Splint | 10 | $11.73 |
| A4580 | Cast supplies (e.g., plaster) | 5 | $10.71 |
| A4595 | Electrical stimulator supplies, 2 lead, per month, (e.g. | 17 | $13.79 |
| A4602 | Replacement battery for external infusion pump owned by... | 10 | $4.83 |
| A4604 | Tubing with integrated heating element for use with positive... | 17 | $49.31 |
| A4605 | Tracheal suction catheter, closed system, each | 20 | $16.53 |
| A4606 | Oxygen probe for use with oximeter device, replacement | 13 | $35.44 |
| A4608 | Transtracheal oxygen catheter, each | 12 | $59.73 |
| A4611 | Battery, heavy duty; replacement for patient owned... | 12 | $155.21 |
| A4612 | Battery cables; replacement for patient-owned ventilator | 12 | $64.38 |
| A4613 | Battery charger; replacement for patient-owned ventilator | 11 | $119.22 |
| A4614 | Peak expiratory flow rate meter, hand held | 19 | $23.13 |
| A4615 | Cannula, nasal | 19 | $0.81 |
| A4616 | Tubing (oxygen), per foot | 17 | $0.07 |
| A4617 | Mouth piece | 13 | $3.49 |
| A4618 | Breathing circuits | 17 | $7.80 |
| A4619 | Face tent | 17 | $2.07 |
| A4620 | Variable concentration mask | 17 | $0.74 |
| A4623 | Tracheostomy, inner cannula | 21 | $6.42 |
| A4624 | Tracheal suction catheter | 21 | $2.38 |
| A4625 | Tracheostomy care kit for new tracheostomy | 19 | $6.83 |
| A4626 | Tracheostomy cleaning brush, each | 17 | $3.18 |
| A4627 | Spacer, bag or reservoir, with or without mask | 15 | $29.51 |
| A4628 | Oral and/or oropharyngeal suction catheter, each | 20 | $3.76 |
| A4629 | Tracheostomy care kit for established tracheostomy | 21 | $4.55 |
| A4630 | Replacement batteries, medically necessary | 13 | $6.56 |
| A4633 | Replacement bulb/lamp for ultraviolet light therapy system | 7 | $47.60 |
| A4635 | Underarm pad, crutch, replacement, each | 22 | $4.12 |
| A4636 | Replacement, handgrip, cane, crutch, or walker, each | 22 | $3.11 |
| A4637 | Replacement, tip, cane, crutch, walker, each. | 22 | $1.90 |
| A4639 | Replacement pad for infrared heating pad system, each | 6 | $252.77 |
| A4640 | Replacement pad for use with medically necessary alternating... | 20 | $44.78 |
| A4657 | Syringe, with or without needle, each | 12 | $0.455 |
| A4660 | Sphygmomanometer/blood pressure apparatus with cuff and... | 16 | $30.00 |
| A4663 | Blood pressure cuff only | 16 | $21.81 |
| A4670 | Automatic blood pressure monitor | 20 | $60.09 |
| A4750 | Blood tubing, arterial or venous, for hemodialysis, each | 5 | $10.00 |
| A4860 | Disposable catheter tips for peritoneal dialysis, per 10 | 5 | $0.67 |
| A4927 | Gloves, non-sterile, per 100 | 20 | $8.65 |
| A4928 | Surgical mask, per 20 | 6 | $18.49 |
| A4930 | Gloves, sterile, per pair | 20 | $0.595 |
| A4931 | Oral thermometer, reusable, any type, each | 9 | $4.80 |
| A4932 | Rectal thermometer, reusable, any type, each | 7 | $3.01 |
| A5051 | Ostomy pouch, closed; with barrier attached (1 piece), each | 21 | $2.17 |
| A5052 | Ostomy pouch, closed; without barrier attached (1 piece) | 21 | $1.49 |
| A5053 | Ostomy pouch, closed; for use on faceplate, each | 20 | $1.73 |
| A5054 | Ostomy pouch, closed; for use on barrier with flange | 21 | $1.70 |
| A5055 | Stoma cap | 21 | $1.41 |
| A5056 | Ostomy pouch, drainable | 21 | $4.93 |
| A5057 | Ostomy pouch, drainable | 21 | $10.16 |
| A5061 | Ostomy pouch, drainable; with barrier attached, (1 piece) | 20 | $3.66 |
| A5062 | Ostomy pouch, drainable; without barrier attached (1 piece) | 21 | $2.23 |
| A5063 | Ostomy pouch, drainable; for use on barrier with flange | 21 | $2.70 |
| A5071 | Ostomy pouch, urinary; with barrier attached (1 piece), each | 21 | $5.10 |
| A5072 | Ostomy pouch, urinary; without barrier attached (1 piece) | 20 | $3.50 |
| A5073 | Ostomy pouch, urinary; for use on barrier with flange | 21 | $3.17 |
| A5081 | Stoma plug or seal, any type | 20 | $3.11 |
| A5082 | Continent device; catheter for continent stoma | 19 | $10.78 |
| A5083 | Continent device, stoma absorptive cover for continent stoma | 15 | $0.75 |
| A5093 | Ostomy accessory; convex insert | 19 | $1.89 |
| A5102 | Bedside drainage bottle with or without tubing | 16 | $23.85 |
| A5105 | Urinary suspensory with leg bag, with or without tube, each | 18 | $40.26 |
| A5112 | Urinary drainage bag, leg or abdomen, latex | 20 | $32.72 |
| A5113 | Leg strap; latex, replacement only, per set | 17 | $4.70 |
| A5114 | Leg strap; foam or fabric, replacement only, per set | 17 | $8.82 |
| A5120 | Skin barrier, wipes or swabs, each | 21 | $0.25 |
| A5121 | Skin barrier; solid, 6 x 6 or equivalent, each | 20 | $7.73 |
| A5122 | Skin barrier; solid, 8 x 8 or equivalent, each | 21 | $12.26 |
| A5126 | Adhesive or non-adhesive; disk or foam pad | 19 | $1.31 |
| A5131 | Appliance cleaner, incontinence and ostomy appliances | 17 | $14.03 |
| A5200 | Percutaneous catheter/tube anchoring device | 17 | $12.09 |
| A5500 | For diabetics only, fitting (including follow-up) | 19 | $66.76 |
| A5501 | For diabetics only, fitting (including follow-up) | 19 | $200.25 |
| A5503 | For diabetics only, modification | 19 | $30.20 |
| A5504 | For diabetics only, modification | 19 | $30.20 |
| A5505 | For diabetics only, modification | 19 | $30.20 |
| A5506 | For diabetics only, modification | 19 | $30.20 |
| A5507 | For diabetics only, not otherwise specified modification | 18 | $31.56 |
| A5510 | For diabetics only, direct formed | 5 | $29.14 |
| A5512 | For diabetics only, multiple density insert, direct formed | 18 | $26.15 |
| A5513 | For diabetics only, multiple density insert | 18 | $39.03 |
| A5514 | For diabetics only, multiple density insert | 15 | $46.89 |
| A6010 | Collagen based wound filler, dry form, sterile | 19 | $32.51 |
| A6011 | Collagen based wound filler, gel/paste, per gram of collagen | 18 | $2.42 |
| A6021 | Collagen dressing, sterile, size 16 sq. in. or less, each | 20 | $21.31 |
| A6022 | Collagen dressing, sterile | 20 | $21.87 |
| A6023 | Collagen dressing, sterile, size more than 48 sq. in., each | 19 | $188.23 |
| A6024 | Collagen dressing wound filler, sterile, per 6 inches | 19 | $6.17 |
| A6025 | Gel sheet for dermal or epidermal application, (e.g. | 7 | $15.30 |
| A6154 | Wound pouch, each | 16 | $15.22 |
| A6196 | Alginate or other fiber gelling dressing, wound cover | 21 | $7.08 |
| A6197 | Alginate or other fiber gelling dressing, wound cover | 21 | $16.41 |
| A6198 | Alginate or other fiber gelling dressing, wound cover | 14 | $19.17 |
| A6199 | Alginate or other fiber gelling dressing, wound filler | 20 | $5.37 |
| A6203 | Composite dressing, sterile, pad size 16 sq. in. or less | 20 | $3.41 |
| A6204 | Composite dressing, sterile | 20 | $6.07 |
| A6205 | Composite dressing, sterile, pad size more than 48 sq. in. | 13 | $5.16 |
| A6206 | Contact layer, sterile, 16 sq. in. or less, each dressing | 15 | $2.00 |
| A6207 | Contact layer, sterile | 20 | $7.52 |
| A6208 | Contact layer, sterile, more than 48 sq. in., each dressing | 11 | $9.24 |
| A6209 | Foam dressing, wound cover, sterile | 20 | $7.58 |
| A6210 | Foam dressing, wound cover, sterile | 20 | $19.69 |
| A6211 | Foam dressing, wound cover, sterile | 20 | $29.76 |
| A6212 | Foam dressing, wound cover, sterile | 20 | $9.47 |
| A6213 | Foam dressing, wound cover, sterile | 17 | $10.13 |
| A6214 | Foam dressing, wound cover, sterile | 19 | $10.90 |
| A6215 | Foam dressing, wound filler, sterile, per gram | 10 | $2.15 |
| A6216 | Gauze, non-impregnated, non-sterile | 21 | $0.05 |
| A6217 | Gauze, non-impregnated, non-sterile | 16 | $0.175 |
| A6218 | Gauze, non-impregnated, non-sterile | 13 | $0.47 |
| A6219 | Gauze, non-impregnated, sterile | 20 | $0.965 |
| A6220 | Gauze, non-impregnated, sterile | 20 | $2.62 |
| A6221 | Gauze, non-impregnated, sterile | 11 | $2.31 |
| A6222 | Gauze, impregnated with other than water, normal saline | 20 | $2.09 |
| A6223 | Gauze, impregnated with other than water, normal saline | 20 | $2.37 |
| A6224 | Gauze, impregnated with other than water, normal saline | 20 | $3.52 |
| A6228 | Gauze, impregnated, water or normal saline, sterile | 7 | $1.64 |
| A6229 | Gauze, impregnated, water or normal saline, sterile | 19 | $3.71 |
| A6230 | Gauze, impregnated, water or normal saline, sterile | 9 | $1.84 |
| A6231 | Gauze, impregnated, hydrogel, for direct wound contact | 18 | $4.92 |
| A6232 | Gauze, impregnated, hydrogel, for direct wound contact | 18 | $7.20 |
| A6233 | Gauze, impregnated, hydrogel, for direct wound contact | 16 | $20.52 |
| A6234 | Hydrocolloid dressing, wound cover, sterile | 20 | $6.58 |
| A6235 | Hydrocolloid dressing, wound cover, sterile | 20 | $16.42 |
| A6236 | Hydrocolloid dressing, wound cover, sterile | 20 | $27.61 |
| A6237 | Hydrocolloid dressing, wound cover, sterile | 20 | $7.72 |
| A6238 | Hydrocolloid dressing, wound cover, sterile | 20 | $22.25 |
| A6239 | Hydrocolloid dressing, wound cover, sterile | 10 | $18.41 |
| A6240 | Hydrocolloid dressing, wound filler, paste, sterile | 20 | $11.95 |
| A6241 | Hydrocolloid dressing, wound filler, dry form, sterile | 20 | $2.61 |
| A6242 | Hydrogel dressing, wound cover, sterile | 20 | $6.14 |
| A6243 | Hydrogel dressing, wound cover, sterile | 20 | $12.02 |
| A6244 | Hydrogel dressing, wound cover, sterile | 19 | $39.19 |
| A6245 | Hydrogel dressing, wound cover, sterile | 20 | $7.37 |
| A6246 | Hydrogel dressing, wound cover, sterile | 20 | $10.06 |
| A6247 | Hydrogel dressing, wound cover, sterile | 19 | $23.72 |
| A6248 | Hydrogel dressing, wound filler, gel, per fluid ounce | 20 | $15.85 |
| A6250 | Skin sealants, protectants, moisturizers, ointments | 11 | $5.16 |
| A6251 | Specialty absorptive dressing, wound cover, sterile | 21 | $2.05 |
| A6252 | Specialty absorptive dressing, wound cover, sterile | 21 | $3.25 |
| A6253 | Specialty absorptive dressing, wound cover, sterile | 20 | $6.43 |
| A6254 | Specialty absorptive dressing, wound cover, sterile | 20 | $1.22 |
| A6255 | Specialty absorptive dressing, wound cover, sterile | 20 | $2.97 |
| A6256 | Specialty absorptive dressing, wound cover, sterile | 11 | $1.62 |
| A6257 | Transparent film, sterile, 16 sq. in. or less, each dressing | 20 | $1.51 |
| A6258 | Transparent film, sterile | 20 | $4.14 |
| A6259 | Transparent film, sterile, more than 48 sq. in. | 20 | $11.20 |
| A6260 | Wound cleansers, any type, any size | 10 | $9.09 |
| A6261 | Wound filler, gel/paste, per fluid ounce | 10 | $3.56 |
| A6262 | Wound filler, dry form, per gram, not otherwise specified | 12 | $0.93 |
| A6266 | Gauze, impregnated, other than water, normal saline | 19 | $2.04 |
| A6402 | Gauze, non-impregnated, sterile | 21 | $0.12 |
| A6403 | Gauze, non-impregnated, sterile | 20 | $0.435 |
| A6404 | Gauze, non-impregnated, sterile | 14 | $0.625 |
| A6407 | Packing strips, non-impregnated, sterile | 18 | $2.01 |
| A6410 | Eye pad, sterile, each | 16 | $0.42 |
| A6411 | Eye pad, non-sterile, each | 11 | $0.24 |
| A6412 | Eye patch, occlusive, each | 11 | $0.42 |
| A6441 | Padding bandage, non-elastic, non-woven/non-knitted | 19 | $0.72 |
| A6442 | Conforming bandage, non-elastic, knitted/woven, non-sterile | 19 | $0.18 |
| A6443 | Conforming bandage, non-elastic, knitted/woven, non-sterile | 20 | $0.295 |
| A6444 | Conforming bandage, non-elastic, knitted/woven, non-sterile | 20 | $0.57 |
| A6445 | Conforming bandage, non-elastic, knitted/woven, sterile | 17 | $0.35 |
| A6446 | Conforming bandage, non-elastic, knitted/woven, sterile | 20 | $0.425 |
| A6447 | Conforming bandage, non-elastic, knitted/woven, sterile | 19 | $0.69 |
| A6448 | Light compression bandage, elastic, knitted/woven | 19 | $1.20 |
| A6449 | Light compression bandage, elastic, knitted/woven | 20 | $1.78 |
| A6450 | Light compression bandage, elastic, knitted/woven | 18 | $1.63 |
| A6451 | Moderate compression bandage, elastic, knitted/woven | 15 | $2.04 |
| A6452 | High compression bandage, elastic, knitted/woven | 17 | $6.33 |
| A6453 | Self-adherent bandage, elastic, non-knitted/non-woven | 18 | $0.65 |
| A6454 | Self-adherent bandage, elastic, non-knitted/non-woven | 18 | $0.81 |
| A6455 | Self-adherent bandage, elastic, non-knitted/non-woven | 17 | $1.50 |
| A6456 | Zinc paste impregnated bandage, non-elastic, knitted/woven | 18 | $1.41 |
| A6457 | Tubular dressing with or without elastic, any width | 20 | $1.20 |
| A6509 | Compression burn garment | 5 | $238.11 |
| A6511 | Compression burn garment | 5 | $150.33 |
| A6520 | Gradient compression garment, glove, padded | 10 | $118.47 |
| A6521 | Gradient compression garment, glove, padded | 9 | $451.58 |
| A6522 | Gradient compression garment, arm, padded | 11 | $276.53 |
| A6523 | Gradient compression garment, arm, padded | 9 | $656.12 |
| A6524 | Gradient compression garment, lower leg and foot, padded | 11 | $345.01 |
| A6525 | Gradient compression garment, lower leg and foot, padded | 10 | $692.11 |
| A6526 | Gradient compression garment, full leg and foot, padded | 12 | $606.43 |
| A6527 | Gradient compression garment, full leg and foot, padded | 10 | $1,139.76 |
| A6528 | Gradient compression garment, bra, for nighttime use, each | 13 | $566.46 |
| A6529 | Gradient compression garment, bra, for nighttime use | 10 | $941.76 |
| A6530 | Gradient compression stocking, below knee, 18-30 mmhg, each | 18 | $34.24 |
| A6531 | Gradient compression stocking, below knee, 30-40 mmhg | 17 | $43.27 |
| A6532 | Gradient compression stocking, below knee, 40-50 mmhg | 17 | $62.80 |
| A6533 | Gradient compression stocking, thigh length, 18-30 mmhg | 18 | $48.00 |
| A6534 | Gradient compression stocking, thigh length, 30-40 mmhg | 18 | $54.82 |
| A6535 | Gradient compression stocking, thigh length | 18 | $67.58 |
| A6536 | Gradient compression stocking, full length/chap style | 18 | $64.71 |
| A6537 | Gradient compression stocking, full length/chap style | 18 | $80.60 |
| A6538 | Gradient compression stocking, full length/chap style | 18 | $93.48 |
| A6539 | Gradient compression stocking, waist length, 18-30 mmhg | 19 | $83.18 |
| A6540 | Gradient compression stocking, waist length, 30-40 mmhg | 18 | $100.71 |
| A6541 | Gradient compression stocking, waist length | 19 | $124.39 |
| A6544 | Gradient compression stocking, garter belt | 15 | $27.69 |
| A6545 | Gradient compression wrap, non-elastic, below knee | 12 | $95.03 |
| A6548 | Accessory to custom gradient compression garment | 9 | $17.73 |
| A6550 | Wound care set, for negative pressure wound therapy... | 18 | $25.10 |
| A6552 | Gradient compression stocking, below knee, 30-40 mmhg, each | 13 | $43.85 |
| A6553 | Gradient compression stocking, below knee, 30-40 mmhg | 11 | $201.17 |
| A6554 | Gradient compression stocking, below knee | 13 | $60.29 |
| A6555 | Gradient compression stocking, below knee | 11 | $201.17 |
| A6556 | Gradient compression stocking, thigh length, 18-30 mmhg | 11 | $275.69 |
| A6557 | Gradient compression stocking, thigh length, 30-40 mmhg | 12 | $277.46 |
| A6558 | Gradient compression stocking, thigh length | 11 | $284.51 |
| A6562 | Gradient compression stocking, waist length, 18-30 mmhg | 11 | $902.29 |
| A6563 | Gradient compression stocking, waist length, 30-40 mmhg | 11 | $902.29 |
| A6564 | Gradient compression stocking, waist length | 11 | $971.96 |
| A6565 | Gradient compression gauntlet, custom, each | 11 | $155.91 |
| A6566 | Gradient compression garment, neck/head, each | 11 | $216.54 |
| A6567 | Gradient compression garment, neck/head, custom, each | 9 | $720.38 |
| A6568 | Gradient compression garment, torso and shoulder, each | 13 | $125.74 |
| A6569 | Gradient compression garment, torso/shoulder, custom, each | 11 | $841.30 |
| A6570 | Gradient compression garment, genital region, each | 12 | $90.99 |
| A6571 | Gradient compression garment, genital region, custom, each | 10 | $608.89 |
| A6572 | Gradient compression garment, toe caps, each | 11 | $79.50 |
| A6573 | Gradient compression garment, toe caps, custom, each | 11 | $221.65 |
| A6574 | Gradient compression arm sleeve and glove combination | 12 | $276.43 |
| A6575 | Gradient compression arm sleeve and glove combination, each | 12 | $85.35 |
| A6576 | Gradient compression arm sleeve, custom, medium weight, each | 11 | $173.43 |
| A6577 | Gradient compression arm sleeve, custom, heavy weight, each | 11 | $143.54 |
| A6578 | Gradient compression arm sleeve, each | 13 | $67.62 |
| A6579 | Gradient compression glove, custom, medium weight, each | 11 | $278.37 |
| A6580 | Gradient compression glove, custom, heavy weight, each | 11 | $276.32 |
| A6581 | Gradient compression glove, each | 12 | $67.23 |
| A6582 | Gradient compression gauntlet, each | 12 | $40.32 |
| A6583 | Gradient compression wrap with adjustable straps | 12 | $128.61 |
| A6585 | Gradient compression wrap with adjustable straps | 10 | $157.02 |
| A6586 | Gradient compression wrap with adjustable straps, full leg | 10 | $462.59 |
| A6587 | Gradient compression wrap with adjustable straps, foot, each | 11 | $62.19 |
| A6588 | Gradient compression wrap with adjustable straps, arm, each | 11 | $207.29 |
| A6589 | Gradient pressure wrap with adjustable straps, bra, each | 12 | $77.32 |
| A6590 | External urinary catheters; disposable | 7 | $312.27 |
| A6591 | External urinary catheter; non-disposable | 6 | $68.95 |
| A6594 | Gradient compression bandaging supply, bandage liner | 10 | $30.67 |
| A6595 | Gradient compression bandaging supply, bandage liner | 10 | $30.17 |
| A6596 | Gradient compression bandaging supply, conforming gauze | 11 | $0.15 |
| A6597 | Gradient compression bandage roll, elastic long stretch | 11 | $1.32 |
| A6598 | Gradient compression bandage roll, elastic medium stretch | 10 | $0.605 |
| A6599 | Gradient compression bandage roll, inelastic short stretch | 11 | $1.45 |
| A6600 | Gradient compression bandaging supply | 11 | $2.61 |
| A6601 | Gradient compression bandaging supply | 11 | $2.93 |
| A6602 | Gradient compression bandaging supply | 11 | $4.28 |
| A6603 | Gradient compression bandaging supply | 11 | $2.01 |
| A6604 | Gradient compression bandaging supply | 11 | $1.17 |
| A6605 | Gradient compression bandaging supply, padded foam | 11 | $1.33 |
| A6606 | Gradient compression bandaging supply, padded textile | 11 | $3.97 |
| A6607 | Gradient compression bandaging supply | 11 | $1.06 |
| A6608 | Gradient compression bandaging supply | 11 | $4.43 |
| A6610 | Gradient compression stocking, below knee, 18-30 mmhg | 10 | $202.46 |
| A7000 | Canister, disposable, used with suction pump, each | 22 | $8.18 |
| A7001 | Canister, non-disposable, used with suction pump, each | 17 | $36.30 |
| A7002 | Tubing, used with suction pump, each | 21 | $3.47 |
| A7003 | Administration set, with small volume nonfiltered pneumatic... | 20 | $2.07 |
| A7004 | Small volume nonfiltered pneumatic nebulizer, disposable | 18 | $1.46 |
| A7005 | Administration set, with small volume nonfiltered pneumatic... | 22 | $18.73 |
| A7006 | Administration set, with small volume filtered pneumatic... | 18 | $8.18 |
| A7007 | Large volume nebulizer, disposable, unfilled | 20 | $3.27 |
| A7008 | Large volume nebulizer, disposable, prefilled | 13 | $12.75 |
| A7009 | Reservoir bottle, non-disposable | 15 | $47.00 |
| A7010 | Corrugated tubing, disposable | 19 | $17.15 |
| A7012 | Water collection device, used with large volume nebulizer | 19 | $3.00 |
| A7013 | Filter, disposable, used with aerosol compressor or... | 19 | $0.65 |
| A7014 | Filter, nondisposable | 18 | $3.55 |
| A7015 | Aerosol mask, used with dme nebulizer | 21 | $1.50 |
| A7016 | Dome and mouthpiece, used with small volume ultrasonic... | 15 | $7.94 |
| A7017 | Nebulizer, durable, glass or autoclavable plastic | 12 | $97.99 |
| A7018 | Water, distilled, used with large volume nebulizer, 1000 ml | 15 | $0.36 |
| A7020 | Interface for cough stimulating device | 16 | $17.37 |
| A7021 | Supplies and accessories for lung expansion airway... | 10 | $113.14 |
| A7025 | High frequency chest wall oscillation system vest | 16 | $374.06 |
| A7026 | High frequency chest wall oscillation system hose | 15 | $30.19 |
| A7027 | Combination oral/nasal mask | 20 | $147.92 |
| A7028 | Oral cushion for combination oral/nasal mask | 19 | $39.80 |
| A7029 | Nasal pillows for combination oral/nasal mask | 19 | $18.67 |
| A7030 | Full face mask used with positive airway pressure device | 21 | $133.28 |
| A7031 | Face mask interface, replacement for full face mask, each | 21 | $45.35 |
| A7032 | Cushion for use on nasal mask interface, replacement only | 21 | $25.51 |
| A7033 | Pillow for use on nasal cannula type interface | 21 | $21.83 |
| A7034 | Nasal interface (mask or cannula type) used with positive... | 21 | $75.19 |
| A7035 | Headgear used with positive airway pressure device | 21 | $24.23 |
| A7036 | Chinstrap used with positive airway pressure device | 21 | $13.23 |
| A7037 | Tubing used with positive airway pressure device | 21 | $22.92 |
| A7038 | Filter, disposable, used with positive airway pressure... | 21 | $3.07 |
| A7039 | Filter, non disposable | 20 | $8.91 |
| A7040 | One way chest drain valve | 6 | $53.35 |
| A7041 | Water seal drainage container and tubing for use with... | 6 | $100.27 |
| A7044 | Oral interface used with positive airway pressure device | 16 | $104.51 |
| A7045 | Exhalation port with or without swivel used with accessories... | 14 | $14.95 |
| A7046 | Water chamber for humidifier | 21 | $15.61 |
| A7047 | Oral interface used with respiratory suction pump, each | 9 | $140.22 |
| A7048 | Vacuum drainage collection unit and tubing kit | 13 | $48.03 |
| A7501 | Tracheostoma valve, including diaphragm, each | 17 | $116.57 |
| A7502 | Replacement diaphragm/faceplate for tracheostoma valve, each | 16 | $56.66 |
| A7503 | Filter holder or filter cap, reusable | 16 | $12.88 |
| A7504 | Filter for use in a tracheostoma heat and moisture exchange... | 16 | $0.77 |
| A7505 | Housing, reusable without adhesive | 15 | $5.44 |
| A7506 | Adhesive disc for use in a heat and moisture exchange system... | 15 | $0.37 |
| A7507 | Filter holder and integrated filter without adhesive | 20 | $2.75 |
| A7508 | Housing and integrated adhesive | 19 | $3.14 |
| A7509 | Filter holder and integrated filter housing, and adhesive | 15 | $1.64 |
| A7520 | Tracheostomy/laryngectomy tube, non-cuffed | 19 | $57.51 |
| A7521 | Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride | 19 | $56.98 |
| A7522 | Tracheostomy/laryngectomy tube, stainless steel or equal | 18 | $53.55 |
| A7523 | Tracheostomy shower protector, each | 9 | $6.80 |
| A7524 | Tracheostoma stent/stud/button, each | 16 | $88.16 |
| A7525 | Tracheostomy mask, each | 21 | $2.06 |
| A7526 | Tracheostomy tube collar/holder, each | 21 | $3.38 |
| A7527 | Tracheostomy/laryngectomy tube plug/stop, each | 16 | $3.92 |
| A8000 | Helmet, protective, soft, prefabricated | 22 | $145.20 |
| A8001 | Helmet, protective, hard, prefabricated | 22 | $145.20 |
| A8002 | Helmet, protective, soft, custom fabricated | 11 | $367.74 |
| A8003 | Helmet, protective, hard, custom fabricated | 10 | $380.63 |
| A8004 | Soft interface for helmet, replacement only | 7 | $75.75 |
| A9274 | External ambulatory insulin delivery system, disposable | 10 | $36.98 |
| A9276 | Sensor; invasive (e.g., subcutaneous), disposable | 6 | $12.88 |
| A9277 | Transmitter; external | 6 | $550.26 |
| A9278 | Receiver (monitor); external | 6 | $536.15 |
| A9286 | Hygienic item or device, disposable or non-disposable | 5 | $0.47 |
| A9500 | Technetium tc-99m sestamibi, diagnostic, per study dose | 15 | $108.26 |
| A9502 | Technetium tc-99m tetrofosmin, diagnostic, per study dose | 16 | $97.03 |
| A9503 | Technetium tc-99m medronate, diagnostic, per study dose | 14 | $19.03 |
| A9504 | Technetium tc-99m apcitide, diagnostic, per study dose | 6 | $418.62 |
| A9505 | Thallium tl-201 thallous chloride, diagnostic | 14 | $34.54 |
| A9507 | Indium in-111 capromab pendetide, diagnostic | 6 | $814.36 |
| A9508 | Iodine i-131 iobenguane sulfate, diagnostic | 8 | $460.96 |
| A9510 | Technetium tc-99m disofenin, diagnostic, per study dose | 8 | $77.28 |
| A9512 | Technetium tc-99m pertechnetate, diagnostic, per millicurie | 6 | $1.76 |
| A9513 | Lutetium lu 177, dotatate, therapeutic, 1 millicurie | 10 | $335.22 |
| A9516 | Iodine i-123 sodium iodide, diagnostic, per 100 microcuries | 8 | $92.80 |
| A9517 | Iodine i-131 sodium iodide capsule(s), therapeutic | 6 | $65.35 |
| A9521 | Technetium tc-99m exametazime, diagnostic, per study dose | 8 | $1,592.21 |
| A9524 | Iodine i-131 iodinated serum albumin, diagnostic | 7 | $65.00 |
| A9526 | Nitrogen n-13 ammonia, diagnostic, per study dose | 8 | $655.71 |
| A9528 | Iodine i-131 sodium iodide capsule(s), diagnostic | 5 | $32.30 |
| A9536 | Technetium tc-99m depreotide, diagnostic, per study dose | 6 | $684.00 |
| A9537 | Technetium tc-99m mebrofenin, diagnostic, per study dose | 9 | $56.50 |
| A9538 | Technetium tc-99m pyrophosphate, diagnostic, per study dose | 9 | $64.05 |
| A9539 | Technetium tc-99m pentetate, diagnostic, per study dose | 5 | $16.25 |
| A9540 | Technetium tc-99m macroaggregated albumin, diagnostic | 8 | $31.02 |
| A9541 | Technetium tc-99m sulfur colloid, diagnostic | 10 | $49.47 |
| A9542 | Indium in-111 ibritumomab tiuxetan, diagnostic | 6 | $3,213.13 |
| A9543 | Yttrium y-90 ibritumomab tiuxetan, therapeutic | 8 | $67,806.71 |
| A9547 | Indium in-111 oxyquinoline, diagnostic, per 0.5 millicurie | 8 | $1,371.31 |
| A9548 | Indium in-111 pentetate, diagnostic, per 0.5 millicurie | 8 | $614.18 |
| A9551 | Technetium tc-99m succimer, diagnostic, per study dose | 6 | $363.03 |
| A9552 | Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose | 9 | $228.00 |
| A9554 | Iodine i-125 sodium iothalamate, diagnostic, per study dose | 6 | $41.40 |
| A9555 | Rubidium rb-82, diagnostic, per study dose | 5 | $494.71 |
| A9556 | Gallium ga-67 citrate, diagnostic, per millicurie | 6 | $110.07 |
| A9557 | Technetium tc-99m bicisate, diagnostic, per study dose | 8 | $413.58 |
| A9558 | Xenon xe-133 gas, diagnostic, per 10 millicuries | 9 | $227.12 |
| A9559 | Cobalt co-57 cyanocobalamin, oral, diagnostic | 5 | $89.36 |
| A9560 | Technetium tc-99m labeled red blood cells, diagnostic | 7 | $90.90 |
| A9561 | Technetium tc-99m oxidronate, diagnostic, per study dose | 7 | $40.34 |
| A9562 | Technetium tc-99m mertiatide, diagnostic, per study dose | 8 | $388.86 |
| A9563 | Sodium phosphate p-32, therapeutic, per millicurie | 8 | $188.13 |
| A9564 | Chromic phosphate p-32 suspension, therapeutic | 7 | $331.13 |
| A9569 | Technetium tc-99m exametazime labeled autologous white blood... | 7 | $1,655.65 |
| A9570 | Indium in-111 labeled autologous white blood cells | 6 | $4,184.66 |
| A9571 | Indium in-111 labeled autologous platelets, diagnostic | 6 | $3,184.87 |
| A9572 | Indium in-111 pentetreotide, diagnostic, per study dose | 6 | $4,001.58 |
| A9573 | Injection, gadopiclenol, 1 ml | 5 | $3.22 |
| A9574 | Injection, ferumoxytol, 1 mg | 6 | $0.415 |
| A9575 | Injection, gadoterate meglumine, 0.1 ml | 11 | $0.09 |
| A9576 | Injection, gadoteridol, (prohance multipack), per ml | 12 | $1.37 |
| A9577 | Injection, gadobenate dimeglumine (multihance), per ml | 12 | $1.80 |
| A9578 | Injection, gadobenate dimeglumine (multihance multipack) | 11 | $1.70 |
| A9579 | Injection, gadolinium-based magnetic resonance contrast... | 13 | $1.44 |
| A9581 | Injection, gadoxetate disodium, 1 ml | 13 | $14.75 |
| A9582 | Iodine i-123 iobenguane, diagnostic, per study dose | 6 | $4,339.73 |
| A9584 | Iodine 1-123 ioflupane, diagnostic, per study dose | 6 | $2,789.97 |
| A9585 | Injection, gadobutrol, 0.1 ml | 13 | $0.26 |
| A9587 | Gallium ga-68, dotatate, diagnostic, 0.1 millicurie | 7 | $64.80 |
| A9589 | Instillation, hexaminolevulinate hydrochloride, 100 mg | 11 | $1,431.00 |
| A9590 | Iodine i-131, iobenguane, 1 millicurie | 7 | $324.85 |
| A9592 | Copper cu-64, dotatate, diagnostic, 1 millicurie | 6 | $1,046.93 |
| A9595 | Piflufolastat f 18 (pylarify), diagnostic, 1 millicurie | 11 | $633.51 |
| A9600 | Strontium sr-89 chloride, therapeutic, per millicurie | 11 | $1,042.35 |
| A9601 | Flortaucipir f 18 injection, diagnostic, 1 millicurie | 5 | $373.80 |
| A9604 | Samarium sm-153 lexidronam, therapeutic, per treatment dose | 5 | $16,282.88 |
| A9606 | Radium ra-223 dichloride, therapeutic, per microcurie | 12 | $176.39 |
| A9607 | Lutetium lu 177 vipivotide tetraxetan, therapeutic | 12 | $268.38 |
| A9608 | Flotufolastat f 18, diagnostic, 1 millicurie | 8 | $703.54 |
| A9800 | Gallium ga-68 gozetotide, diagnostic, (locametz) | 6 | $690.28 |
| B4034 | Enteral feeding supply kit; syringe fed, per day | 21 | $5.17 |
| B4035 | Enteral feeding supply kit; pump fed, per day | 21 | $9.65 |
| B4036 | Enteral feeding supply kit; gravity fed, per day | 21 | $6.80 |
| B4081 | Nasogastric tubing with stylet | 21 | $18.53 |
| B4082 | Nasogastric tubing without stylet | 21 | $13.97 |
| B4083 | Stomach tube - levine type | 20 | $2.10 |
| B4087 | Gastrostomy/jejunostomy tube, standard, any material | 20 | $30.91 |
| B4088 | Enteral and parenteral nutrition | 19 | $93.33 |
| B4100 | Food thickener, administered orally, per ounce | 9 | $0.72 |
| B4102 | Enteral formula, for adults | 8 | $1.81 |
| B4103 | Enteral formula, for pediatrics | 11 | $2.92 |
| B4105 | In-line cartridge containing digestive enzyme(s) for enteral... | 8 | $114.70 |
| B4149 | Enteral formula, manufactured blenderized natural foods with... | 18 | $1.56 |
| B4150 | Enteral formula, nutritionally complete with intact... | 19 | $0.65 |
| B4152 | Enteral formula, nutritionally complete, calorically dense | 19 | $0.53 |
| B4153 | Enteral formula, nutritionally complete | 20 | $1.88 |
| B4154 | Enteral formula, nutritionally complete | 20 | $1.18 |
| B4155 | Enteral formula, nutritionally incomplete/modular nutrients | 20 | $0.945 |
| B4157 | Enteral formula, nutritionally complete | 9 | $3.35 |
| B4158 | Enteral formula, for pediatrics | 13 | $0.76 |
| B4159 | Enteral formula, for pediatrics | 12 | $0.8542 |
| B4160 | Enteral formula, for pediatrics | 14 | $0.845 |
| B4161 | Enteral formula, for pediatrics | 13 | $2.11 |
| B4162 | Enteral formula, for pediatrics | 9 | $3.86 |
| B4164 | Parenteral nutrition solution: carbohydrates (dextrose) | 12 | $18.25 |
| B4168 | Parenteral nutrition solution; amino acid, 3.5%, | 12 | $26.62 |
| B4172 | Parenteral nutrition solution; amino acid, 5.5% through 7%, | 8 | $35.31 |
| B4176 | Parenteral nutrition solution; amino acid, 7% through 8.5%, | 12 | $51.50 |
| B4178 | Parenteral nutrition solution: amino acid | 12 | $61.81 |
| B4180 | Parenteral nutrition solution; carbohydrates (dextrose) | 12 | $26.21 |
| B4185 | Parenteral nutrition solution, not otherwise specified | 15 | $11.63 |
| B4187 | Omegaven, 10 grams lipids | 8 | $12.02 |
| B4189 | Parenteral nutrition solution | 13 | $184.14 |
| B4193 | Parenteral nutrition solution | 13 | $237.93 |
| B4197 | Parenteral nutrition solution | 13 | $289.68 |
| B4199 | Parenteral nutrition solution | 13 | $331.01 |
| B4216 | Parenteral nutrition; additives (vitamins, trace elements | 12 | $8.64 |
| B4220 | Parenteral nutrition supply kit; premix, per day | 16 | $8.60 |
| B4222 | Parenteral nutrition supply kit; home mix, per day | 14 | $11.04 |
| B4224 | Parenteral nutrition administration kit, per day | 18 | $26.86 |
| B5000 | Enteral and parenteral nutrition | 13 | $13.65 |
| B5100 | Enteral and parenteral nutrition | 13 | $5.31 |
| B5200 | Enteral and parenteral nutrition | 9 | $5.43 |
| B9002 | Enteral nutrition infusion pump, any type | 22 | $88.18 |
| B9004 | Parenteral nutrition infusion pump, portable | 19 | $365.00 |
| B9006 | Parenteral nutrition infusion pump, stationary | 17 | $413.77 |
| B9998 | Noc for enteral supplies | 6 | $17.85 |
| E0100 | Cane, includes canes of all materials, adjustable or fixed | 22 | $14.64 |
| E0105 | Cane, quad or three prong, includes canes of all materials | 22 | $39.16 |
| E0110 | Crutches, forearm, includes crutches of various materials | 21 | $57.44 |
| E0111 | Crutch forearm, includes crutches of various materials | 21 | $33.85 |
| E0112 | Crutches underarm, wood, adjustable or fixed, pair | 21 | $22.83 |
| E0113 | Crutch underarm, wood, adjustable or fixed, each, with pad | 21 | $11.45 |
| E0114 | Crutches underarm, other than wood, adjustable or fixed | 21 | $29.49 |
| E0116 | Crutch, underarm, other than wood, adjustable or fixed | 20 | $15.89 |
| E0117 | Crutch, underarm, articulating, spring assisted, each | 12 | $27.18 |
| E0118 | Crutch substitute, lower leg platform | 5 | $64.68 |
| E0130 | Walker, rigid (pickup), adjustable or fixed height | 22 | $34.61 |
| E0135 | Walker, folding (pickup), adjustable or fixed height | 22 | $42.71 |
| E0140 | Walker, with trunk support, adjustable or fixed height | 17 | $37.56 |
| E0141 | Durable medical equipment | 22 | $22.27 |
| E0143 | Walker, folding, wheeled, adjustable or fixed height | 22 | $34.23 |
| E0144 | Walker, enclosed, four sided framed, rigid or folding | 16 | $33.91 |
| E0147 | Walker, heavy duty, multiple braking system | 20 | $51.64 |
| E0148 | Walker, heavy duty, without wheels, rigid or folding | 21 | $60.45 |
| E0149 | Walker, heavy duty, wheeled, rigid or folding, any type | 22 | $17.86 |
| E0153 | Platform attachment, forearm crutch, each | 21 | $51.30 |
| E0154 | Platform attachment, walker, each | 22 | $51.77 |
| E0155 | Wheel attachment, rigid pick-up walker, per pair | 22 | $23.67 |
| E0156 | Durable medical equipment | 21 | $18.39 |
| E0157 | Crutch attachment, walker, each | 21 | $47.32 |
| E0158 | Leg extensions for walker, per set of four (4) | 21 | $21.42 |
| E0159 | Brake attachment for wheeled walker, replacement, each | 18 | $14.94 |
| E0160 | Sitz type bath or equipment, portable | 15 | $21.63 |
| E0161 | Sitz type bath or equipment, portable | 13 | $22.87 |
| E0162 | Sitz bath chair | 10 | $18.80 |
| E0163 | Commode chair, mobile or stationary, with fixed arms | 22 | $38.22 |
| E0165 | Durable medical equipment | 22 | $90.78 |
| E0167 | Pail or pan for use with commode chair, replacement only | 22 | $7.99 |
| E0168 | Commode chair, extra wide and/or heavy duty | 21 | $88.21 |
| E0170 | Commode chair with integrated seat lift mechanism, electric | 10 | $207.98 |
| E0171 | Commode chair with integrated seat lift mechanism | 11 | $33.66 |
| E0175 | Foot rest, for use with commode chair, each | 17 | $56.54 |
| E0181 | Powered pressure reducing mattress overlay/pad, alternating | 21 | $19.84 |
| E0182 | Pump for alternating pressure pad, for replacement only | 20 | $60.15 |
| E0183 | Powered pressure reducing underlay/pad, alternating | 11 | $16.81 |
| E0184 | Dry pressure mattress | 22 | $123.23 |
| E0185 | Gel or gel-like pressure pad for mattress | 22 | $72.80 |
| E0186 | Air pressure mattress | 20 | $22.90 |
| E0187 | Water pressure mattress | 20 | $26.21 |
| E0188 | Synthetic sheepskin pad | 19 | $17.77 |
| E0189 | Lambswool sheepskin pad, any size | 18 | $38.41 |
| E0190 | Positioning cushion/pillow/wedge, any shape or size | 10 | $35.25 |
| E0191 | Heel or elbow protector, each | 19 | $8.74 |
| E0193 | Powered air flotation bed (low air loss therapy) | 17 | $669.13 |
| E0194 | Air fluidized bed | 17 | $2,766.93 |
| E0196 | Gel pressure mattress | 20 | $37.91 |
| E0197 | Air pressure pad for mattress | 22 | $27.35 |
| E0198 | Water pressure pad for mattress | 20 | $44.86 |
| E0199 | Dry pressure pad for mattress | 20 | $23.35 |
| E0200 | Heat lamp, without stand (table model), includes bulb | 12 | $23.37 |
| E0201 | Penile contracture device, manual | 5 | $84.47 |
| E0202 | Phototherapy (bilirubin) light with photometer | 21 | $62.61 |
| E0205 | Heat lamp, with stand, includes bulb, or infrared element | 12 | $54.06 |
| E0210 | Electric heat pad, standard | 11 | $24.09 |
| E0215 | Electric heat pad, moist | 12 | $33.56 |
| E0217 | Water circulating heat pad with pump | 14 | $72.20 |
| E0221 | Infrared heating pad system | 5 | $1,690.77 |
| E0225 | Hydrocollator unit, includes pads | 7 | $329.62 |
| E0235 | Paraffin bath unit, portable | 15 | $24.58 |
| E0236 | Pump for water circulating pad | 11 | $53.60 |
| E0239 | Hydrocollator unit, portable | 5 | $391.29 |
| E0240 | Bath/shower chair, with or without wheels, any size | 12 | $103.54 |
| E0241 | Bath tub wall rail, each | 13 | $24.00 |
| E0242 | Bath tub rail, floor base | 7 | $69.79 |
| E0243 | Toilet rail, each | 14 | $37.18 |
| E0244 | Raised toilet seat | 18 | $41.70 |
| E0245 | Tub stool or bench | 16 | $37.49 |
| E0246 | Transfer tub rail attachment | 15 | $50.64 |
| E0247 | Transfer bench for tub or toilet with or without commode... | 14 | $92.88 |
| E0248 | Transfer bench, heavy duty | 13 | $163.22 |
| E0249 | Pad for water circulating heat unit, for replacement only | 12 | $57.11 |
| E0250 | Hospital bed, fixed height, with any type side rails | 18 | $83.21 |
| E0251 | Hospital bed, fixed height, with any type side rails | 15 | $66.97 |
| E0255 | Hospital bed, variable height, hi-lo | 19 | $80.56 |
| E0256 | Hospital bed, variable height, hi-lo | 16 | $72.00 |
| E0260 | Hospital bed, semi-electric (head and foot adjustment) | 19 | $112.37 |
| E0261 | Hospital bed, semi-electric (head and foot adjustment) | 17 | $75.89 |
| E0265 | Hospital bed, total electric (head | 18 | $179.51 |
| E0266 | Hospital bed, total electric (head | 15 | $147.95 |
| E0271 | Mattress, innerspring | 22 | $91.59 |
| E0272 | Mattress, foam rubber | 20 | $94.70 |
| E0273 | Bed board | 5 | $44.73 |
| E0274 | Over-bed table | 7 | $44.55 |
| E0275 | Bed pan, standard, metal or plastic | 18 | $10.41 |
| E0276 | Bed pan, fracture, metal or plastic | 20 | $9.53 |
| E0277 | Powered pressure-reducing air mattress | 18 | $264.09 |
| E0280 | Bed cradle, any type | 13 | $33.32 |
| E0290 | Hospital bed, fixed height, without side rails | 14 | $68.33 |
| E0291 | Hospital bed, fixed height, without side rails | 15 | $49.09 |
| E0292 | Hospital bed, variable height, hi-lo, without side rails | 14 | $74.37 |
| E0293 | Hospital bed, variable height, hi-lo, without side rails | 15 | $64.66 |
| E0294 | Hospital bed, semi-electric (head and foot adjustment) | 14 | $81.09 |
| E0295 | Hospital bed, semi-electric (head and foot adjustment) | 15 | $76.74 |
| E0296 | Hospital bed, total electric (head | 12 | $140.19 |
| E0297 | Hospital bed, total electric (head | 12 | $120.33 |
| E0300 | Pediatric crib, hospital grade, fully enclosed | 14 | $276.77 |
| E0301 | Hospital bed, heavy duty, extra wide | 16 | $208.35 |
| E0302 | Hospital bed, extra heavy duty, extra wide | 15 | $572.35 |
| E0303 | Hospital bed, heavy duty, extra wide | 20 | $234.94 |
| E0304 | Hospital bed, extra heavy duty, extra wide | 19 | $523.77 |
| E0305 | Bed side rails, half length | 21 | $15.23 |
| E0310 | Bed side rails, full length | 22 | $74.73 |
| E0315 | Bed accessory: board, table, or support device, any type | 8 | $43.92 |
| E0316 | Safety enclosure frame/canopy for use with hospital bed | 16 | $214.22 |
| E0325 | Urinal; male, jug-type, any material | 19 | $6.77 |
| E0326 | Urinal; female, jug-type, any material | 19 | $7.79 |
| E0328 | Hospital bed, pediatric, manual, 360 degree side enclosures | 8 | $2,777.40 |
| E0329 | Hospital bed, pediatric, electric or semi-electric | 5 | $5,400.00 |
| E0370 | Air pressure elevator for heel | 6 | $8.53 |
| E0371 | Nonpowered advanced pressure reducing overlay for mattress | 18 | $268.70 |
| E0372 | Powered air overlay for mattress | 18 | $225.13 |
| E0373 | Nonpowered advanced pressure reducing mattress | 16 | $403.11 |
| E0424 | Stationary compressed gaseous oxygen system, rental | 20 | $100.50 |
| E0431 | Portable gaseous oxygen system, rental | 21 | $25.15 |
| E0433 | Portable liquid oxygen system, rental | 11 | $41.30 |
| E0434 | Portable liquid oxygen system, rental | 21 | $40.00 |
| E0439 | Stationary liquid oxygen system, rental; includes container | 20 | $129.13 |
| E0441 | Stationary oxygen contents, gaseous | 20 | $65.91 |
| E0442 | Stationary oxygen contents, liquid | 20 | $65.91 |
| E0443 | Portable oxygen contents, gaseous, 1 month's supply = 1 unit | 19 | $49.79 |
| E0444 | Portable oxygen contents, liquid, 1 month's supply = 1 unit | 19 | $49.79 |
| E0445 | Oximeter device for measuring blood oxygen levels... | 21 | $193.51 |
| E0447 | Portable oxygen contents, liquid, 1 month's supply = 1 unit | 11 | $73.75 |
| E0455 | Oxygen tent, excluding croup or pediatric tents | 8 | $17.03 |
| E0457 | Chest shell (cuirass) | 12 | $246.59 |
| E0459 | Chest wrap | 10 | $61.32 |
| E0462 | Rocking bed with or without side rails | 9 | $285.01 |
| E0465 | Home ventilator, any type, used with invasive interface, | 22 | $939.32 |
| E0466 | Home ventilator, any type, used with non-invasive interface | 22 | $939.32 |
| E0467 | Home ventilator, multi-function respiratory device | 17 | $1,169.02 |
| E0468 | Home ventilator, dual-function respiratory device | 12 | $1,037.34 |
| E0469 | Lung expansion airway clearance | 9 | $1,219.71 |
| E0470 | Respiratory assist device, bi-level pressure capability | 22 | $183.19 |
| E0471 | Respiratory assist device, bi-level pressure capability | 22 | $369.18 |
| E0472 | Respiratory assist device, bi-level pressure capability | 18 | $416.85 |
| E0480 | Percussor, electric or pneumatic, home model | 20 | $50.63 |
| E0481 | Intrapulmonary percussive ventilation system and related... | 6 | $1,094.66 |
| E0482 | Cough stimulating device | 22 | $495.05 |
| E0483 | High frequency chest wall oscillation system | 22 | $1,210.88 |
| E0484 | Oscillatory positive expiratory pressure device | 17 | $32.13 |
| E0486 | Oral device/appliance used to reduce upper airway... | 5 | $1,374.30 |
| E0500 | Durable medical equipment | 20 | $103.45 |
| E0530 | Electronic positional obstructive sleep apnea treatment | 5 | $35.53 |
| E0550 | Humidifier, durable for extensive supplemental... | 19 | $50.13 |
| E0555 | Humidifier, durable, glass or autoclavable plastic bottle... | 13 | $21.36 |
| E0560 | Humidifier, durable for supplemental humidification during... | 13 | $76.00 |
| E0561 | Humidifier, non-heated | 22 | $9.68 |
| E0562 | Humidifier, heated, used with positive airway pressure... | 22 | $23.39 |
| E0565 | Compressor, air power source for equipment which is not... | 21 | $51.57 |
| E0570 | Nebulizer, with compressor | 22 | $48.26 |
| E0572 | Aerosol compressor, adjustable pressure | 11 | $29.51 |
| E0574 | Ultrasonic/electronic aerosol generator with small volume... | 15 | $50.19 |
| E0575 | Nebulizer, ultrasonic, large volume | 18 | $138.26 |
| E0580 | Nebulizer, durable, glass or autoclavable plastic | 14 | $58.48 |
| E0585 | Nebulizer, with compressor and heater | 17 | $29.81 |
| E0600 | Respiratory suction pump, home model | 22 | $54.38 |
| E0601 | Continuous positive airway pressure (cpap) device | 22 | $75.73 |
| E0602 | Breast pump, manual, any type | 19 | $25.00 |
| E0603 | Breast pump, electric (ac and/or dc), any type | 21 | $155.33 |
| E0604 | Breast pump, hospital grade, electric (ac and / or dc) | 18 | $49.08 |
| E0605 | Vaporizer, room type | 15 | $16.90 |
| E0606 | Postural drainage board | 15 | $28.62 |
| E0607 | Home blood glucose monitor | 15 | $59.01 |
| E0610 | Pacemaker monitor, self-contained, | 11 | $175.88 |
| E0615 | Pacemaker monitor, self contained | 10 | $249.13 |
| E0617 | External defibrillator with integrated electrocardiogram... | 10 | $457.19 |
| E0618 | Apnea monitor, without recording feature | 13 | $325.16 |
| E0619 | Apnea monitor, with recording feature | 20 | $216.54 |
| E0621 | Sling or seat, patient lift, canvas or nylon | 21 | $68.88 |
| E0627 | Seat lift mechanism, electric, any type | 12 | $189.84 |
| E0629 | Seat lift mechanism, non-electric, any type | 12 | $189.37 |
| E0630 | Durable medical equipment | 22 | $74.45 |
| E0635 | Patient lift, electric with seat or sling | 17 | $144.38 |
| E0636 | Multipositional patient support system | 10 | $1,175.80 |
| E0637 | Combination sit to stand frame/table system | 9 | $409.43 |
| E0638 | Standing frame/table system, one position (e.g., upright | 11 | $640.18 |
| E0639 | Patient lift, moveable from room to room with disassembly... | 8 | $147.06 |
| E0640 | Patient lift, fixed system | 6 | $122.12 |
| E0641 | Standing frame/table system, multi-position (e.g. | 6 | $1,257.25 |
| E0650 | Pneumatic compressor, non-segmental home model | 20 | $105.44 |
| E0651 | Pneumatic compressor | 19 | $111.25 |
| E0652 | Pneumatic compressor | 17 | $653.36 |
| E0655 | Non-segmental pneumatic appliance for use with pneumatic... | 20 | $36.21 |
| E0656 | Segmental pneumatic appliance for use with pneumatic... | 13 | $82.35 |
| E0657 | Segmental pneumatic appliance for use with pneumatic... | 13 | $349.51 |
| E0658 | Segmental pneumatic appliance for use with pneumatic... | 10 | $138.10 |
| E0659 | Segmental pneumatic appliance for use with pneumatic... | 10 | $138.10 |
| E0660 | Non-segmental pneumatic appliance for use with pneumatic... | 20 | $47.41 |
| E0665 | Non-segmental pneumatic appliance for use with pneumatic... | 20 | $46.08 |
| E0666 | Non-segmental pneumatic appliance for use with pneumatic... | 20 | $54.88 |
| E0667 | Segmental pneumatic appliance for use with pneumatic... | 18 | $43.86 |
| E0668 | Segmental pneumatic appliance for use with pneumatic... | 18 | $52.31 |
| E0669 | Segmental pneumatic appliance for use with pneumatic... | 17 | $26.12 |
| E0670 | Segmental pneumatic appliance for use with pneumatic... | 15 | $159.81 |
| E0671 | Segmental gradient pressure pneumatic appliance, full leg | 17 | $59.23 |
| E0672 | Segmental gradient pressure pneumatic appliance, full arm | 17 | $46.03 |
| E0673 | Segmental gradient pressure pneumatic appliance, half leg | 17 | $38.22 |
| E0675 | Pneumatic compression device, high pressure | 9 | $445.99 |
| E0677 | Non-pneumatic sequential compression garment, trunk | 7 | $76.85 |
| E0678 | Non-pneumatic sequential compression garment, full leg | 11 | $37.89 |
| E0679 | Non-pneumatic sequential compression garment, half leg | 11 | $23.75 |
| E0680 | Non-pneumatic compression controller with sequential... | 10 | $631.39 |
| E0681 | Non-pneumatic compression controller without calibrated... | 9 | $106.89 |
| E0682 | Non-pneumatic sequential compression garment, full arm | 11 | $52.48 |
| E0683 | Non-pneumatic, non-sequential | 8 | $79.80 |
| E0691 | Ultraviolet light therapy system, includes bulbs/lamps | 9 | $775.97 |
| E0692 | Ultraviolet light therapy system panel | 8 | $567.59 |
| E0693 | Ultraviolet light therapy system panel | 7 | $1,209.92 |
| E0694 | Ultraviolet multidirectional light therapy system in 6 foot... | 8 | $3,918.72 |
| E0700 | Safety equipment, device or accessory, any type | 8 | $24.98 |
| E0705 | Transfer device, any type, each | 21 | $39.25 |
| E0710 | Restraints, any type (body, chest, wrist or ankle) | 7 | $13.79 |
| E0720 | Transcutaneous electrical nerve stimulation (tens) device | 18 | $37.00 |
| E0730 | Transcutaneous electrical nerve stimulation (tens) device | 19 | $44.39 |
| E0731 | Form fitting conductive garment for delivery of tens or nmes... | 14 | $87.62 |
| E0732 | Cranial electrotherapy stimulation (ces) system, any type | 6 | $45.14 |
| E0733 | Transcutaneous electrical nerve stimulator for electrical... | 7 | $40.12 |
| E0734 | External upper limb tremor stimulator of the peripheral... | 5 | $429.24 |
| E0735 | Non-invasive vagus nerve stimulator | 6 | $45.14 |
| E0736 | Transcutaneous tibial nerve stimulator | 6 | $40.96 |
| E0740 | Non-implanted pelvic floor electrical stimulator | 11 | $74.52 |
| E0743 | External lower extremity nerve stimulator for restless legs... | 7 | $181.79 |
| E0744 | Neuromuscular stimulator for scoliosis | 11 | $106.21 |
| E0745 | Neuromuscular stimulator, electronic shock unit | 13 | $127.58 |
| E0747 | Osteogenesis stimulator, electrical, non-invasive | 20 | $1,838.60 |
| E0748 | Osteogenesis stimulator, electrical, non-invasive | 19 | $2,818.60 |
| E0749 | Osteogenesis stimulator, electrical, surgically implanted | 5 | $1,746.00 |
| E0760 | Osteogenesis stimulator, low intensity ultrasound | 17 | $2,342.20 |
| E0762 | Transcutaneous electrical joint stimulation device system | 6 | $107.97 |
| E0765 | Fda approved nerve stimulator | 6 | $78.62 |
| E0766 | Electrical stimulation device used for cancer treatment | 14 | $12,231.55 |
| E0776 | Iv pole | 21 | $17.73 |
| E0779 | Ambulatory infusion pump, mechanical, reusable | 16 | $19.54 |
| E0780 | Ambulatory infusion pump, mechanical, reusable | 17 | $9.40 |
| E0781 | Ambulatory infusion pump, single or multiple channels | 21 | $248.56 |
| E0782 | Infusion pump, implantable, non-programmable | 8 | $4,213.51 |
| E0783 | Infusion pump system, implantable, programmable | 10 | $7,457.44 |
| E0784 | External ambulatory infusion pump, insulin | 21 | $491.41 |
| E0785 | Implantable intraspinal | 8 | $538.08 |
| E0786 | Implantable programmable infusion pump, replacement | 9 | $8,721.06 |
| E0791 | Parenteral infusion pump, stationary | 19 | $250.47 |
| E0840 | Traction frame, attached to headboard, cervical traction | 18 | $34.34 |
| E0849 | Traction equipment, cervical, free-standing stand/frame | 12 | $68.86 |
| E0850 | Traction stand, free standing, cervical traction | 17 | $17.98 |
| E0855 | Cervical traction equipment not requiring additional stand... | 11 | $70.23 |
| E0856 | Cervical traction device, with inflatable air bladder(s) | 8 | $141.33 |
| E0860 | Traction equipment, overdoor, cervical | 19 | $21.57 |
| E0870 | Traction frame, attached to footboard, extremity traction, | 17 | $28.50 |
| E0880 | Traction stand, free standing, extremity traction | 17 | $28.09 |
| E0890 | Traction frame, attached to footboard, pelvic traction | 20 | $46.88 |
| E0900 | Traction stand, free standing, pelvic traction, (e.g. | 19 | $39.37 |
| E0910 | Trapeze bars, a/k/a patient helper, attached to bed | 22 | $15.89 |
| E0911 | Trapeze bar, heavy duty | 19 | $48.31 |
| E0912 | Trapeze bar, heavy duty | 19 | $97.36 |
| E0920 | Fracture frame, attached to bed, includes weights | 18 | $52.13 |
| E0930 | Fracture frame, free standing, includes weights | 18 | $47.15 |
| E0935 | Continuous passive motion exercise device for use on knee... | 19 | $22.73 |
| E0936 | Continuous passive motion exercise device for use other than... | 6 | $21.82 |
| E0940 | Trapeze bar, free standing, complete with grab bar | 22 | $27.28 |
| E0941 | Gravity assisted traction device, any type | 14 | $50.81 |
| E0942 | Cervical head harness/halter | 19 | $16.65 |
| E0944 | Pelvic belt/harness/boot | 20 | $36.00 |
| E0945 | Extremity belt/harness | 18 | $30.89 |
| E0946 | Fracture, frame, dual with cross bars, attached to bed, | 16 | $65.04 |
| E0947 | Fracture frame, attachments for complex pelvic traction | 18 | $73.64 |
| E0948 | Fracture frame, attachments for complex cervical traction | 17 | $71.03 |
| E0950 | Durable medical equipment | 21 | $88.43 |
| E0951 | Heel loop/holder, any type, with or without ankle strap | 22 | $15.36 |
| E0952 | Toe loop/holder, any type, each | 22 | $14.57 |
| E0953 | Wheelchair accessory, lateral thigh or knee support | 20 | $57.64 |
| E0954 | Wheelchair accessory, foot box, any type | 19 | $40.95 |
| E0955 | Wheelchair accessory, headrest, cushioned, any type | 21 | $161.74 |
| E0956 | Wheelchair accessory, lateral trunk or hip support | 22 | $71.87 |
| E0957 | Wheelchair accessory, medial thigh support, any type | 21 | $117.34 |
| E0958 | Manual wheelchair accessory, one-arm drive attachment, each | 21 | $332.42 |
| E0959 | Manual wheelchair accessory, adapter for amputee, each | 22 | $37.75 |
| E0960 | Wheelchair accessory | 22 | $79.71 |
| E0961 | Manual wheelchair accessory, wheel lock brake extension | 22 | $21.71 |
| E0966 | Manual wheelchair accessory, headrest extension, each | 21 | $61.05 |
| E0967 | Manual wheelchair accessory, hand rim with projections | 22 | $63.81 |
| E0968 | Commode seat, wheelchair | 14 | $67.65 |
| E0969 | Narrowing device, wheelchair | 16 | $135.14 |
| E0970 | No. 2 footplates, except for elevating leg rest | 11 | $41.21 |
| E0971 | Manual wheelchair accessory, anti-tipping device, each | 22 | $36.10 |
| E0973 | Wheelchair accessory, adjustable height, detachable armrest | 22 | $64.49 |
| E0974 | Manual wheelchair accessory, anti-rollback device, each | 22 | $65.37 |
| E0978 | Wheelchair accessory | 22 | $30.13 |
| E0980 | Safety vest, wheelchair | 17 | $28.79 |
| E0981 | Wheelchair accessory, seat upholstery, replacement only | 21 | $37.72 |
| E0982 | Wheelchair accessory, back upholstery, replacement only | 21 | $41.22 |
| E0983 | Manual wheelchair accessory | 18 | $319.54 |
| E0984 | Manual wheelchair accessory | 18 | $823.81 |
| E0985 | Wheelchair accessory, seat lift mechanism | 13 | $173.44 |
| E0986 | Manual wheelchair accessory, power assist system | 18 | $2,474.33 |
| E0988 | Manual wheelchair accessory, lever-activated, wheel drive | 11 | $333.82 |
| E0990 | Wheelchair accessory, elevating leg rest, complete assembly | 22 | $77.81 |
| E0992 | Manual wheelchair accessory, solid seat insert | 22 | $74.71 |
| E0994 | Arm rest, each | 17 | $16.91 |
| E0995 | Wheelchair accessory, calf rest/pad, replacement only, each | 22 | $23.90 |
| E1002 | Wheelchair accessory, power seating system, tilt only | 22 | $3,295.21 |
| E1003 | Wheelchair accessory, power seating system, recline only | 20 | $3,472.99 |
| E1004 | Wheelchair accessory, power seating system, recline only | 20 | $4,037.42 |
| E1005 | Wheelchair accessory, power seating system, recline only | 20 | $3,948.55 |
| E1006 | Wheelchair accessory, power seating system | 19 | $4,805.45 |
| E1007 | Wheelchair accessory, power seating system | 21 | $6,993.02 |
| E1008 | Wheelchair accessory, power seating system | 20 | $6,769.53 |
| E1010 | Wheelchair accessory, addition to power seating system | 19 | $908.97 |
| E1012 | Wheelchair accessory, addition to power seating system | 15 | $139.14 |
| E1014 | Reclining back, addition to pediatric size wheelchair | 20 | $175.83 |
| E1015 | Shock absorber for manual wheelchair, each | 17 | $100.47 |
| E1016 | Shock absorber for power wheelchair, each | 17 | $111.71 |
| E1020 | Residual limb support system for wheelchair, any type | 21 | $207.07 |
| E1028 | Wheelchair accessory, manual swingaway | 20 | $163.97 |
| E1029 | Wheelchair accessory, ventilator tray, fixed | 19 | $278.65 |
| E1030 | Wheelchair accessory, ventilator tray, gimbaled | 19 | $143.14 |
| E1031 | Rollabout chair, any and all types with casters 5" or... | 15 | $52.04 |
| E1032 | Wheelchair accessory, manual swingaway | 17 | $20.31 |
| E1033 | Wheelchair accessory, manual swingaway | 17 | $20.31 |
| E1034 | Wheelchair accessory, manual swingaway | 17 | $20.31 |
| E1035 | Multi-positional patient transfer system | 15 | $668.74 |
| E1036 | Multi-positional patient transfer system, extra-wide | 8 | $1,010.83 |
| E1037 | Transport chair, pediatric size | 13 | $138.01 |
| E1038 | Transport chair, adult size | 14 | $18.06 |
| E1039 | Transport chair, adult size, heavy duty | 13 | $37.33 |
| E1050 | Fully-reclining wheelchair, fixed full length arms | 12 | $102.64 |
| E1060 | Fully-reclining wheelchair, detachable arms | 14 | $139.63 |
| E1070 | Fully-reclining wheelchair, detachable arms | 12 | $119.91 |
| E1083 | Hemi-wheelchair, fixed full length arms | 12 | $89.85 |
| E1084 | Hemi-wheelchair, detachable arms desk or full length arms | 12 | $115.42 |
| E1085 | Hemi-wheelchair, fixed full length arms | 8 | $71.56 |
| E1086 | Hemi-wheelchair detachable arms desk or full length | 9 | $132.65 |
| E1087 | High strength lightweight wheelchair | 12 | $150.02 |
| E1088 | High strength lightweight wheelchair | 12 | $170.34 |
| E1089 | High strength lightweight wheelchair, fixed length arms | 9 | $122.56 |
| E1090 | High strength lightweight wheelchair | 10 | $159.50 |
| E1092 | Wide heavy duty wheel chair, detachable arms | 12 | $129.51 |
| E1093 | Wide heavy duty wheelchair | 12 | $114.51 |
| E1100 | Semi-reclining wheelchair, fixed full length arms | 12 | $123.07 |
| E1110 | Semi-reclining wheelchair, detachable arms | 11 | $114.35 |
| E1130 | Standard wheelchair, fixed full length arms | 9 | $188.30 |
| E1140 | Wheelchair, detachable arms, desk or full length | 9 | $83.67 |
| E1150 | Wheelchair, detachable arms | 13 | $94.93 |
| E1160 | Wheelchair, fixed full length arms | 13 | $72.76 |
| E1161 | Manual adult size wheelchair, includes tilt in space | 22 | $337.19 |
| E1170 | Amputee wheelchair, fixed full length arms | 13 | $91.98 |
| E1171 | Amputee wheelchair, fixed full length arms | 12 | $91.45 |
| E1172 | Amputee wheelchair, detachable arms | 12 | $108.74 |
| E1180 | Amputee wheelchair, detachable arms | 13 | $104.35 |
| E1190 | Amputee wheelchair, detachable arms | 13 | $120.54 |
| E1195 | Heavy duty wheelchair, fixed full length arms | 12 | $143.14 |
| E1200 | Amputee wheelchair, fixed full length arms | 13 | $100.39 |
| E1221 | Wheelchair with fixed arm, footrests | 11 | $53.39 |
| E1222 | Wheelchair with fixed arm, elevating legrests | 11 | $74.57 |
| E1223 | Wheelchair with detachable arms, footrests | 11 | $72.39 |
| E1224 | Wheelchair with detachable arms, elevating legrests | 11 | $79.37 |
| E1225 | Wheelchair accessory, manual semi-reclining back, | 20 | $41.96 |
| E1226 | Wheelchair accessory, manual fully reclining back, | 22 | $267.10 |
| E1227 | Special height arms for wheelchair | 14 | $239.23 |
| E1228 | Special back height for wheelchair | 15 | $34.95 |
| E1230 | Power operated vehicle | 13 | $1,707.13 |
| E1231 | Wheelchair, pediatric size, tilt-in-space, rigid | 7 | $220.45 |
| E1232 | Wheelchair, pediatric size, tilt-in-space, folding | 20 | $248.47 |
| E1233 | Wheelchair, pediatric size, tilt-in-space, rigid | 21 | $257.87 |
| E1234 | Wheelchair, pediatric size, tilt-in-space, folding | 21 | $240.55 |
| E1235 | Wheelchair, pediatric size, rigid, adjustable | 20 | $228.32 |
| E1236 | Wheelchair, pediatric size, folding, adjustable | 21 | $198.52 |
| E1237 | Wheelchair, pediatric size, rigid, adjustable | 20 | $192.05 |
| E1238 | Wheelchair, pediatric size, folding, adjustable | 20 | $194.29 |
| E1240 | Lightweight wheelchair, detachable arms, | 13 | $106.27 |
| E1250 | Lightweight wheelchair, fixed full length arms | 8 | $78.71 |
| E1260 | Lightweight wheelchair, detachable arms | 10 | $105.96 |
| E1270 | Lightweight wheelchair, fixed full length arms | 13 | $91.55 |
| E1280 | Heavy duty wheelchair, detachable arms | 13 | $152.23 |
| E1285 | Heavy duty wheelchair, fixed full length arms | 9 | $119.96 |
| E1290 | Heavy duty wheelchair, detachable arms | 10 | $145.55 |
| E1295 | Heavy duty wheelchair, fixed full length arms | 13 | $134.48 |
| E1296 | Special wheelchair seat height from floor | 16 | $407.57 |
| E1297 | Special wheelchair seat depth, by upholstery | 17 | $85.51 |
| E1298 | Special wheelchair seat depth and/or width, by construction | 17 | $331.29 |
| E1300 | Whirlpool, portable (overtub type) | 6 | $161.72 |
| E1310 | Whirlpool, non-portable (built-in type) | 8 | $1,813.97 |
| E1353 | Regulator | 13 | $32.84 |
| E1355 | Stand/rack | 13 | $24.75 |
| E1372 | Immersion external heater for nebulizer | 16 | $102.01 |
| E1390 | Oxygen concentrator, single delivery port | 21 | $126.23 |
| E1391 | Oxygen concentrator, dual delivery port | 12 | $90.62 |
| E1392 | Durable medical equipment | 18 | $41.07 |
| E1399 | Durable medical equipment, miscellaneous | 7 | $302.44 |
| E1405 | Oxygen and water vapor enriching system with heated delivery | 11 | $134.18 |
| E1406 | Oxygen and water vapor enriching system without heated... | 12 | $131.05 |
| E1510 | Kidney, dialysate delivery syst kidney machine | 6 | $558.78 |
| E1594 | Cycler dialysis machine for peritoneal dialysis | 5 | $561.36 |
| E1600 | Delivery and/or installation charges for hemodialysis... | 5 | $294.69 |
| E1639 | Scale, each | 5 | $29.28 |
| E1700 | Jaw motion rehabilitation system | 11 | $37.64 |
| E1701 | Replacement cushions for jaw motion rehabilitation system | 9 | $12.03 |
| E1702 | Replacement measuring scales for jaw motion rehabilitation... | 8 | $25.69 |
| E1800 | Dynamic adjustable elbow extension and flexion device | 18 | $119.97 |
| E1801 | Static progressive stretch/patient actualized serial stretch... | 15 | $136.60 |
| E1802 | Dynamic adjustable forearm pronation/supination device | 14 | $367.88 |
| E1803 | Dynamic adjustable elbow extension only device | 12 | $130.56 |
| E1804 | Dynamic adjustable elbow flexion only device | 12 | $130.56 |
| E1805 | Dynamic adjustable wrist extension and flexion device | 17 | $126.89 |
| E1806 | Static progressive stretch wrist device | 15 | $117.23 |
| E1807 | Dynamic adjustable wrist extension only device | 11 | $146.31 |
| E1808 | Dynamic adjustable wrist flexion only device | 11 | $146.31 |
| E1810 | Dynamic adjustable knee extension and flexion device | 19 | $122.83 |
| E1811 | Static progressive stretch/patient actualized serial stretch... | 15 | $142.02 |
| E1812 | Dynamic knee, extension/flexion device with active... | 13 | $96.12 |
| E1813 | Dynamic adjustable knee extension only device | 12 | $137.53 |
| E1814 | Dynamic adjustable knee flexion only device | 12 | $137.53 |
| E1815 | Dynamic adjustable ankle extension and flexion device | 17 | $126.89 |
| E1816 | Static progressive stretch/patient actualized serial stretch... | 15 | $133.52 |
| E1818 | Static progressive stretch/patient actualized serial stretch... | 15 | $147.23 |
| E1820 | Replacement soft interface material | 14 | $40.85 |
| E1821 | Replacement soft interface material/cuffs for bi-directional... | 13 | $91.57 |
| E1822 | Dynamic adjustable ankle extension only device | 11 | $146.73 |
| E1823 | Dynamic adjustable ankle flexion only device | 11 | $146.73 |
| E1825 | Dynamic adjustable finger extension and flexion device | 16 | $134.72 |
| E1826 | Dynamic adjustable finger extension only device | 11 | $146.31 |
| E1827 | Dynamic adjustable finger flexion only device | 11 | $146.31 |
| E1828 | Dynamic adjustable toe extension only device | 10 | $161.43 |
| E1829 | Dynamic adjustable toe flexion only device | 10 | $161.43 |
| E1830 | Dynamic adjustable toe extension and flexion device | 14 | $149.80 |
| E1831 | Static progressive stretch toe device | 8 | $72.91 |
| E1832 | Static progressive stretch finger device | 6 | $85.08 |
| E1840 | Dynamic adjustable shoulder flexion / abduction / rotation... | 15 | $443.87 |
| E1841 | Static progressive stretch/patient actualized serial stretch... | 11 | $525.37 |
| E2000 | Gastric suction pump, home model, portable or stationary | 15 | $49.65 |
| E2001 | Suction pump, home model, portable or stationary, electric | 6 | $58.97 |
| E2100 | Blood glucose monitor with integrated voice synthesizer | 17 | $88.66 |
| E2101 | Blood glucose monitor with integrated lancing/blood sample | 12 | $164.16 |
| E2102 | Adjunctive, non-implanted continuous glucose monitor or... | 17 | $169.75 |
| E2103 | Non-adjunctive, non-implanted continuous glucose monitor or... | 16 | $204.10 |
| E2104 | Home blood glucose monitor for use with integrated... | 8 | $45.92 |
| E2201 | Manual wheelchair accessory, nonstandard seat frame | 22 | $314.53 |
| E2202 | Manual wheelchair accessory, nonstandard seat frame width | 22 | $393.83 |
| E2203 | Manual wheelchair accessory, nonstandard seat frame depth | 22 | $403.03 |
| E2204 | Manual wheelchair accessory, nonstandard seat frame depth | 22 | $631.11 |
| E2205 | Manual wheelchair accessory, handrim without projections | 21 | $31.06 |
| E2206 | Manual wheelchair accessory, wheel lock assembly, complete | 22 | $39.39 |
| E2207 | Wheelchair accessory, crutch and cane holder, each | 21 | $37.21 |
| E2208 | Wheelchair accessory, cylinder tank carrier, each | 20 | $80.28 |
| E2209 | Accessory, arm trough, with or without hand support, each | 22 | $80.49 |
| E2210 | Wheelchair accessory, bearings, any type, replacement only | 22 | $5.77 |
| E2211 | Manual wheelchair accessory, pneumatic propulsion tire | 22 | $28.51 |
| E2212 | Manual wheelchair accessory | 22 | $5.52 |
| E2213 | Manual wheelchair accessory | 22 | $26.84 |
| E2214 | Manual wheelchair accessory, pneumatic caster tire | 22 | $26.22 |
| E2215 | Manual wheelchair accessory, tube for pneumatic caster tire | 22 | $8.26 |
| E2216 | Manual wheelchair accessory, foam filled propulsion tire | 17 | $25.86 |
| E2217 | Manual wheelchair accessory, foam filled caster tire | 17 | $30.82 |
| E2218 | Manual wheelchair accessory, foam propulsion tire, any size | 21 | $31.86 |
| E2219 | Manual wheelchair accessory, foam caster tire, any size | 22 | $31.49 |
| E2220 | Manual wheelchair accessory, solid | 22 | $23.94 |
| E2221 | Manual wheelchair accessory, solid | 22 | $22.73 |
| E2222 | Manual wheelchair accessory, solid | 21 | $19.41 |
| E2224 | Manual wheelchair accessory, propulsion wheel excludes tire | 22 | $80.77 |
| E2225 | Manual wheelchair accessory, caster wheel excludes tire | 22 | $16.20 |
| E2226 | Manual wheelchair accessory, caster fork, any size | 22 | $32.18 |
| E2227 | Manual wheelchair accessory, gear reduction drive wheel | 16 | $264.01 |
| E2228 | Manual wheelchair accessory, wheel braking system and lock | 16 | $117.99 |
| E2231 | Manual wheelchair accessory, solid seat support base | 21 | $118.76 |
| E2291 | Back, planar, for pediatric size wheelchair including fixed... | 7 | $350.00 |
| E2292 | Seat, planar, for pediatric size wheelchair including fixed... | 7 | $350.00 |
| E2293 | Back, contoured, for pediatric size wheelchair including... | 5 | $434.14 |
| E2294 | Seat, contoured, for pediatric size wheelchair including... | 5 | $434.14 |
| E2298 | Complex rehabilitative power wheelchair accessory | 13 | $206.22 |
| E2310 | Power wheelchair accessory | 21 | $929.99 |
| E2311 | Power wheelchair accessory | 21 | $1,882.81 |
| E2312 | Power wheelchair accessory, hand or chin control interface | 19 | $1,551.34 |
| E2313 | Power wheelchair accessory | 21 | $256.11 |
| E2321 | Power wheelchair accessory, hand control interface | 20 | $1,244.59 |
| E2322 | Power wheelchair accessory, hand control interface | 18 | $1,164.05 |
| E2323 | Power wheelchair accessory | 21 | $63.04 |
| E2324 | Power wheelchair accessory | 20 | $40.23 |
| E2325 | Power wheelchair accessory, sip and puff interface | 21 | $1,114.81 |
| E2326 | Power wheelchair accessory | 21 | $297.98 |
| E2327 | Power wheelchair accessory, head control interface | 21 | $2,222.35 |
| E2328 | Power wheelchair accessory | 21 | $3,878.75 |
| E2329 | Power wheelchair accessory, head control interface | 21 | $1,461.88 |
| E2330 | Power wheelchair accessory, head control interface | 21 | $2,937.52 |
| E2340 | Power wheelchair accessory, nonstandard seat frame width | 21 | $330.42 |
| E2341 | Power wheelchair accessory, nonstandard seat frame width | 20 | $473.58 |
| E2342 | Power wheelchair accessory, nonstandard seat frame depth | 20 | $421.64 |
| E2343 | Power wheelchair accessory, nonstandard seat frame depth | 20 | $674.63 |
| E2351 | Power wheelchair accessory | 18 | $597.35 |
| E2359 | Power wheelchair accessory | 22 | $164.81 |
| E2360 | Power wheelchair accessory | 21 | $83.66 |
| E2361 | Power wheelchair accessory, 22nf sealed lead acid battery | 22 | $124.78 |
| E2362 | Power wheelchair accessory | 20 | $80.64 |
| E2363 | Power wheelchair accessory | 22 | $163.28 |
| E2364 | Power wheelchair accessory | 20 | $82.81 |
| E2365 | Power wheelchair accessory, u-1 sealed lead acid battery | 21 | $91.16 |
| E2366 | Power wheelchair accessory, battery charger, single mode | 22 | $176.45 |
| E2367 | Power wheelchair accessory, battery charger, dual mode | 20 | $291.64 |
| E2368 | Power wheelchair component, drive wheel motor | 22 | $449.67 |
| E2369 | Power wheelchair component, drive wheel gear box | 22 | $384.50 |
| E2370 | Power wheelchair component | 22 | $642.27 |
| E2371 | Power wheelchair accessory | 22 | $124.19 |
| E2372 | Power wheelchair accessory | 8 | $154.50 |
| E2373 | Power wheelchair accessory, hand or chin control interface | 22 | $645.46 |
| E2374 | Power wheelchair accessory, hand or chin control interface | 22 | $443.51 |
| E2375 | Power wheelchair accessory, non-expandable controller | 22 | $682.98 |
| E2376 | Power wheelchair accessory, expandable controller | 21 | $1,065.50 |
| E2377 | Power wheelchair accessory, expandable controller | 21 | $388.57 |
| E2378 | Power wheelchair component, actuator, replacement only | 14 | $69.82 |
| E2381 | Power wheelchair accessory, pneumatic drive wheel tire | 22 | $62.70 |
| E2382 | Power wheelchair accessory | 22 | $17.16 |
| E2383 | Power wheelchair accessory | 22 | $123.64 |
| E2384 | Power wheelchair accessory, pneumatic caster tire, any size | 22 | $64.77 |
| E2385 | Power wheelchair accessory, tube for pneumatic caster tire | 22 | $42.44 |
| E2386 | Power wheelchair accessory, foam filled drive wheel tire | 22 | $120.46 |
| E2387 | Power wheelchair accessory, foam filled caster tire | 22 | $56.67 |
| E2388 | Power wheelchair accessory, foam drive wheel tire, any size | 22 | $45.59 |
| E2389 | Power wheelchair accessory, foam caster tire, any size | 22 | $25.12 |
| E2390 | Power wheelchair accessory, solid | 22 | $39.08 |
| E2391 | Power wheelchair accessory, solid | 22 | $18.87 |
| E2392 | Power wheelchair accessory, solid | 22 | $48.99 |
| E2394 | Power wheelchair accessory, drive wheel excludes tire | 22 | $66.16 |
| E2395 | Power wheelchair accessory, caster wheel excludes tire | 22 | $46.59 |
| E2396 | Power wheelchair accessory, caster fork, any size | 22 | $50.98 |
| E2397 | Power wheelchair accessory, lithium-based battery, each | 12 | $398.06 |
| E2398 | Wheelchair accessory, dynamic positioning hardware for back | 10 | $122.80 |
| E2402 | Negative pressure wound therapy electrical pump | 21 | $707.99 |
| E2500 | Speech generating device, digitized speech | 20 | $318.59 |
| E2502 | Speech generating device, digitized speech | 20 | $863.90 |
| E2504 | Speech generating device, digitized speech | 20 | $1,139.58 |
| E2506 | Speech generating device, digitized speech | 19 | $2,011.85 |
| E2508 | Speech generating device, synthesized speech | 19 | $509.71 |
| E2510 | Speech generating device, synthesized speech | 18 | $3,074.13 |
| E2513 | Accessory for speech generating device | 6 | $1,488.69 |
| E2601 | General use wheelchair seat cushion | 22 | $47.43 |
| E2602 | General use wheelchair seat cushion | 21 | $99.93 |
| E2603 | Skin protection wheelchair seat cushion | 21 | $124.91 |
| E2604 | Skin protection wheelchair seat cushion | 21 | $160.28 |
| E2605 | Positioning wheelchair seat cushion | 21 | $228.98 |
| E2606 | Positioning wheelchair seat cushion | 21 | $342.52 |
| E2607 | Skin protection and positioning wheelchair seat cushion | 21 | $236.19 |
| E2608 | Skin protection and positioning wheelchair seat cushion | 21 | $283.20 |
| E2611 | General use wheelchair back cushion | 21 | $214.38 |
| E2612 | General use wheelchair back cushion | 21 | $346.31 |
| E2613 | Positioning wheelchair back cushion, posterior | 21 | $314.43 |
| E2614 | Positioning wheelchair back cushion, posterior | 21 | $462.72 |
| E2615 | Positioning wheelchair back cushion, posterior-lateral | 21 | $372.07 |
| E2616 | Positioning wheelchair back cushion, posterior-lateral | 21 | $484.13 |
| E2619 | Replacement cover for wheelchair seat cushion or back... | 20 | $45.99 |
| E2620 | Positioning wheelchair back cushion | 21 | $444.04 |
| E2621 | Positioning wheelchair back cushion | 22 | $491.17 |
| E2622 | Skin protection wheelchair seat cushion, adjustable | 21 | $263.42 |
| E2623 | Skin protection wheelchair seat cushion, adjustable | 21 | $335.19 |
| E2624 | Skin protection and positioning wheelchair seat cushion | 21 | $280.09 |
| E2625 | Skin protection and positioning wheelchair seat cushion | 21 | $346.63 |
| E2626 | Wheelchair accessory, shoulder elbow | 18 | $563.63 |
| E2627 | Wheelchair accessory, shoulder elbow | 17 | $827.63 |
| E2628 | Wheelchair accessory, shoulder elbow | 17 | $673.35 |
| E2629 | Wheelchair accessory, shoulder elbow | 17 | $871.19 |
| E2630 | Wheelchair accessory, shoulder elbow, mobile arm support | 17 | $561.04 |
| E2631 | Wheelchair accessory, addition to mobile arm support | 17 | $226.60 |
| E2632 | Wheelchair accessory, addition to mobile arm support | 17 | $151.56 |
| E2633 | Wheelchair accessory, addition to mobile arm support | 17 | $128.04 |
| E3000 | Speech volume modulation system, any type | 5 | $229.72 |
| K0001 | Standard wheelchair | 22 | $37.82 |
| K0002 | Standard hemi (low seat) wheelchair | 22 | $64.70 |
| K0003 | Lightweight wheelchair | 22 | $63.00 |
| K0004 | High strength, lightweight wheelchair | 22 | $90.05 |
| K0005 | Ultralightweight wheelchair | 22 | $1,286.56 |
| K0006 | Heavy duty wheelchair | 22 | $91.12 |
| K0007 | Extra heavy duty wheelchair | 21 | $140.41 |
| K0009 | Other manual wheelchair/base | 13 | $89.12 |
| K0010 | Standard - weight frame motorized/power wheelchair | 15 | $495.90 |
| K0011 | Standard - weight frame motorized/power wheelchair with... | 13 | $638.81 |
| K0012 | Lightweight portable motorized/power wheelchair | 14 | $429.58 |
| K0015 | Detachable, non-adjustable height armrest, replacement only | 22 | $133.43 |
| K0017 | Detachable, adjustable height armrest, base | 22 | $42.67 |
| K0018 | Detachable, adjustable height armrest, upper portion | 22 | $23.97 |
| K0019 | Arm pad, replacement only, each | 22 | $13.65 |
| K0020 | Fixed, adjustable height armrest, pair | 21 | $38.04 |
| K0037 | High mount flip-up footrest, each | 22 | $39.40 |
| K0038 | Leg strap, each | 22 | $20.78 |
| K0039 | Leg strap, h style, each | 22 | $45.36 |
| K0040 | Adjustable angle footplate, each | 22 | $61.44 |
| K0041 | Large size footplate, each | 22 | $43.12 |
| K0042 | Standard size footplate, replacement only, each | 22 | $28.95 |
| K0043 | Footrest, lower extension tube, replacement only, each | 22 | $17.49 |
| K0044 | Footrest, upper hanger bracket, replacement only, each | 21 | $14.68 |
| K0045 | Footrest, complete assembly, replacement only, each | 22 | $48.89 |
| K0046 | Elevating legrest, lower extension tube, replacement only | 22 | $16.87 |
| K0047 | Elevating legrest, upper hanger bracket, replacement only | 22 | $63.18 |
| K0050 | Ratchet assembly, replacement only | 21 | $27.62 |
| K0051 | Cam release assembly, footrest or legrest, replacement only | 21 | $44.41 |
| K0052 | Swingaway, detachable footrests, replacement only, each | 22 | $72.29 |
| K0053 | Elevating footrests, articulating (telescoping), each | 21 | $85.36 |
| K0056 | Seat height less than 17" or equal to or greater than 21"... | 22 | $77.59 |
| K0065 | Spoke protectors, each | 21 | $37.07 |
| K0069 | Rear wheel assembly, complete, with solid tire | 21 | $82.62 |
| K0070 | Rear wheel assembly, complete, with pneumatic tire | 21 | $148.73 |
| K0071 | Front caster assembly, complete, with pneumatic tire | 22 | $92.73 |
| K0072 | Front caster assembly, complete, with semi-pneumatic tire | 22 | $55.82 |
| K0073 | Caster pin lock, each | 22 | $27.29 |
| K0077 | Front caster assembly, complete, with solid tire | 22 | $47.99 |
| K0098 | Drive belt for power wheelchair, replacement only | 18 | $22.44 |
| K0105 | Iv hanger, each | 21 | $88.15 |
| K0195 | Elevating leg rests, pair | 18 | $15.55 |
| K0455 | Infusion pump used for uninterrupted parenteral... | 8 | $280.28 |
| K0552 | Supplies for external non-insulin drug infusion pump | 16 | $2.69 |
| K0601 | Replacement battery for external infusion pump owned by... | 17 | $1.22 |
| K0602 | Replacement battery for external infusion pump owned by... | 17 | $6.91 |
| K0603 | Replacement battery for external infusion pump owned by... | 18 | $0.60 |
| K0604 | Replacement battery for external infusion pump owned by... | 17 | $6.66 |
| K0605 | Replacement battery for external infusion pump owned by... | 15 | $15.92 |
| K0606 | Automatic external defibrillator | 19 | $2,163.95 |
| K0607 | Replacement battery for automated external defibrillator | 10 | $27.69 |
| K0608 | Replacement garment for use with automated external... | 7 | $105.43 |
| K0609 | Replacement electrodes for use with automated external... | 8 | $1,030.56 |
| K0672 | Addition to lower extremity orthosis | 12 | $78.62 |
| K0730 | Controlled dose inhalation drug delivery system | 11 | $208.84 |
| K0733 | Power wheelchair accessory | 21 | $24.17 |
| K0738 | Portable gaseous oxygen system, rental | 16 | $43.58 |
| K0739 | Repair or nonroutine service for durable medical equipment... | 21 | $16.47 |
| K0740 | Repair or nonroutine service for oxygen equipment requiring... | 8 | $17.49 |
| K0800 | Durable medical equipment | 21 | $103.42 |
| K0801 | Power operated vehicle, group 1 heavy duty | 21 | $185.40 |
| K0802 | Power operated vehicle, group 1 very heavy duty | 21 | $250.80 |
| K0806 | Power operated vehicle, group 2 standard | 20 | $607.76 |
| K0807 | Power operated vehicle, group 2 heavy duty | 20 | $941.88 |
| K0808 | Power operated vehicle, group 2 very heavy duty | 20 | $413.46 |
| K0813 | Power wheelchair, group 1 standard, portable | 21 | $321.25 |
| K0814 | Power wheelchair, group 1 standard, portable | 21 | $328.46 |
| K0815 | Durable medical equipment | 21 | $369.49 |
| K0816 | Power wheelchair, group 1 standard, captains chair | 21 | $349.56 |
| K0820 | Power wheelchair, group 2 standard, portable | 21 | $334.47 |
| K0821 | Power wheelchair, group 2 standard, portable | 21 | $345.91 |
| K0822 | Durable medical equipment | 21 | $387.27 |
| K0823 | Durable medical equipment | 21 | $364.99 |
| K0824 | Power wheelchair, group 2 heavy duty, sling/solid seat/back | 21 | $517.89 |
| K0825 | Power wheelchair, group 2 heavy duty, captains chair | 21 | $475.29 |
| K0826 | Power wheelchair, group 2 very heavy duty | 21 | $790.16 |
| K0827 | Power wheelchair, group 2 very heavy duty, captains chair | 21 | $732.74 |
| K0828 | Power wheelchair, group 2 extra heavy duty | 21 | $999.24 |
| K0829 | Power wheelchair, group 2 extra heavy duty, captains chair | 21 | $1,061.38 |
| K0830 | Power wheelchair, group 2 standard, seat elevator | 12 | $1,523.52 |
| K0831 | Power wheelchair, group 2 standard, seat elevator | 12 | $1,085.05 |
| K0835 | Power wheelchair, group 2 standard, single power option | 22 | $449.35 |
| K0836 | Power wheelchair, group 2 standard, single power option | 22 | $466.07 |
| K0837 | Power wheelchair, group 2 heavy duty, single power option | 22 | $576.34 |
| K0838 | Power wheelchair, group 2 heavy duty, single power option | 22 | $510.83 |
| K0839 | Power wheelchair, group 2 very heavy duty | 21 | $765.58 |
| K0840 | Power wheelchair, group 2 extra heavy duty | 22 | $1,170.64 |
| K0841 | Power wheelchair, group 2 standard, multiple power option | 22 | $506.38 |
| K0842 | Power wheelchair, group 2 standard, multiple power option | 22 | $505.64 |
| K0843 | Power wheelchair, group 2 heavy duty, multiple power option | 22 | $600.26 |
| K0848 | Power wheelchair, group 3 standard, sling/solid seat/back | 22 | $879.91 |
| K0849 | Power wheelchair, group 3 standard, captains chair | 22 | $845.97 |
| K0850 | Power wheelchair, group 3 heavy duty, sling/solid seat/back | 22 | $1,020.63 |
| K0851 | Power wheelchair, group 3 heavy duty, captains chair | 22 | $981.36 |
| K0852 | Power wheelchair, group 3 very heavy duty | 22 | $1,179.28 |
| K0853 | Power wheelchair, group 3 very heavy duty, captains chair | 22 | $1,211.43 |
| K0854 | Power wheelchair, group 3 extra heavy duty | 22 | $1,604.88 |
| K0855 | Power wheelchair, group 3 extra heavy duty, captains chair | 22 | $1,516.04 |
| K0856 | Power wheelchair, group 3 standard, single power option | 22 | $944.46 |
| K0857 | Power wheelchair, group 3 standard, single power option | 21 | $1,020.65 |
| K0858 | Power wheelchair, group 3 heavy duty, single power option | 22 | $1,171.81 |
| K0859 | Power wheelchair, group 3 heavy duty, single power option | 22 | $1,117.55 |
| K0860 | Power wheelchair, group 3 very heavy duty | 22 | $1,674.08 |
| K0861 | Power wheelchair, group 3 standard, multiple power option | 22 | $945.98 |
| K0862 | Power wheelchair, group 3 heavy duty, multiple power option | 22 | $1,171.81 |
| K0863 | Power wheelchair, group 3 very heavy duty | 21 | $1,773.57 |
| K0864 | Power wheelchair, group 3 extra heavy duty | 21 | $1,873.76 |
| K0884 | Power wheelchair, group 4 standard, multiple power option | 6 | $5,907.00 |
| K1005 | Disposable collection and storage bag for breast milk | 6 | $0.295 |
| K1034 | Provision of covid-19 test | 7 | $12.00 |
| L0112 | Cranial cervical orthosis, congenital torticollis type | 20 | $1,329.45 |
| L0113 | Cranial cervical orthosis, torticollis type | 15 | $267.09 |
| L0120 | Cervical, flexible, non-adjustable, prefabricated | 22 | $21.33 |
| L0130 | Cervical, flexible, thermoplastic collar, molded to patient | 22 | $166.14 |
| L0140 | Cervical, semi-rigid, adjustable (plastic collar) | 22 | $54.40 |
| L0150 | Cervical, semi-rigid, adjustable molded chin cup | 22 | $97.61 |
| L0160 | Cervical, semi-rigid | 21 | $132.94 |
| L0170 | Cervical, collar, molded to patient model | 22 | $558.09 |
| L0172 | Cervical, collar, semi-rigid thermoplastic foam, two-piece | 22 | $107.82 |
| L0174 | Cervical, collar, semi-rigid, thermoplastic foam | 22 | $235.15 |
| L0180 | Cervical, multiple post collar | 22 | $344.88 |
| L0190 | Cervical, multiple post collar | 22 | $428.24 |
| L0200 | Cervical, multiple post collar | 22 | $430.64 |
| L0220 | Thoracic, rib belt, custom fabricated | 22 | $112.25 |
| L0450 | Tlso, flexible, provides trunk support | 22 | $132.06 |
| L0452 | Tlso, flexible, provides trunk support | 15 | $264.68 |
| L0454 | Tlso flexible, provides trunk support | 22 | $301.94 |
| L0455 | Tlso, flexible, provides trunk support | 21 | $255.37 |
| L0456 | Tlso, flexible, provides trunk support, thoracic region | 22 | $865.86 |
| L0457 | Tlso, flexible, provides trunk support, thoracic region | 21 | $693.44 |
| L0458 | Tlso, triplanar control, modular segmented spinal system | 22 | $806.96 |
| L0460 | Tlso, triplanar control, modular segmented spinal system | 22 | $873.91 |
| L0462 | Tlso, triplanar control, modular segmented spinal system | 22 | $1,129.75 |
| L0464 | Tlso, triplanar control, modular segmented spinal system | 22 | $1,294.06 |
| L0466 | Tlso, sagittal control | 22 | $315.36 |
| L0467 | Tlso, sagittal control | 21 | $279.36 |
| L0468 | Tlso, sagittal-coronal control | 22 | $385.52 |
| L0469 | Tlso, sagittal-coronal control | 20 | $355.53 |
| L0470 | Tlso, triplanar control | 22 | $576.24 |
| L0472 | Tlso, triplanar control, hyperextension | 22 | $360.79 |
| L0480 | Tlso, triplanar control | 22 | $1,386.88 |
| L0482 | Tlso, triplanar control | 22 | $1,499.67 |
| L0484 | Tlso, triplanar control | 22 | $1,532.97 |
| L0486 | Tlso, triplanar control | 22 | $1,646.10 |
| L0488 | Tlso, triplanar control | 21 | $912.92 |
| L0490 | Tlso, sagittal-coronal control | 22 | $258.57 |
| L0491 | Tlso, sagittal-coronal control | 21 | $692.36 |
| L0492 | Tlso, sagittal-coronal control | 20 | $455.10 |
| L0621 | Sacroiliac orthosis, flexible | 21 | $71.06 |
| L0622 | Sacroiliac orthosis, flexible | 22 | $231.72 |
| L0623 | Orthotics and prosthetics | 17 | $108.33 |
| L0624 | Sacroiliac orthosis, provides pelvic-sacral support | 5 | $219.80 |
| L0625 | Lumbar orthosis, flexible, provides lumbar support | 22 | $41.57 |
| L0626 | Lumbar orthosis, sagittal control | 22 | $67.15 |
| L0627 | Lumbar orthosis, sagittal control | 22 | $348.16 |
| L0628 | Lumbar-sacral orthosis, flexible | 22 | $63.05 |
| L0629 | Lumbar-sacral orthosis, flexible | 9 | $176.75 |
| L0630 | Lumbar-sacral orthosis, sagittal control | 22 | $137.16 |
| L0631 | Lumbar-sacral orthosis, sagittal control | 21 | $877.00 |
| L0632 | Orthotics and prosthetics | 7 | $648.98 |
| L0633 | Lumbar-sacral orthosis, sagittal-coronal control | 21 | $250.00 |
| L0634 | Orthotics and prosthetics | 7 | $357.73 |
| L0635 | Lumbar-sacral orthosis, sagittal-coronal control | 21 | $852.94 |
| L0636 | Lumbar sacral orthosis, sagittal-coronal control | 21 | $1,258.56 |
| L0637 | Lumbar-sacral orthosis, sagittal-coronal control | 22 | $1,057.36 |
| L0638 | Lumbar-sacral orthosis, sagittal-coronal control | 22 | $1,156.78 |
| L0639 | Lumbar-sacral orthosis, sagittal-coronal control | 22 | $1,044.00 |
| L0640 | Lumbar-sacral orthosis, sagittal-coronal control | 22 | $885.39 |
| L0641 | Lumbar orthosis, sagittal control | 20 | $57.38 |
| L0642 | Lumbar orthosis, sagittal control | 20 | $302.67 |
| L0643 | Lumbar-sacral orthosis, sagittal control | 20 | $119.26 |
| L0648 | Lumbar-sacral orthosis, sagittal control | 21 | $755.89 |
| L0649 | Lumbar-sacral orthosis, sagittal-coronal control | 21 | $211.14 |
| L0650 | Lumbar-sacral orthosis, sagittal-coronal control | 21 | $791.02 |
| L0651 | Lumbar-sacral orthosis, sagittal-coronal control | 20 | $875.11 |
| L0700 | Cervical-thoracic-lumbar-sacral-orthoses (ctlso) | 22 | $1,676.60 |
| L0710 | Ctlso, anterior-posterior-lateral-control | 22 | $1,883.57 |
| L0720 | Cervical-thoracic-lumbar-sacral-orthoses (ctlso) | 14 | $1,877.62 |
| L0810 | Halo procedure, cervical halo incorporated into jacket vest | 21 | $2,060.45 |
| L0820 | Halo procedure, cervical halo incorporated into plaster body... | 21 | $1,737.53 |
| L0830 | Halo procedure, cervical halo incorporated into milwaukee... | 21 | $2,522.38 |
| L0859 | Addition to halo procedure | 20 | $1,018.40 |
| L0861 | Addition to halo procedure | 19 | $194.31 |
| L0970 | Tlso, corset front | 22 | $96.17 |
| L0972 | Lso, corset front | 22 | $87.81 |
| L0974 | Tlso, full corset | 22 | $146.98 |
| L0976 | Lso, full corset | 22 | $134.94 |
| L0978 | Axillary crutch extension | 21 | $154.84 |
| L0980 | Peroneal straps, prefabricated, off-the-shelf, pair | 21 | $14.05 |
| L0982 | Stocking supporter grips, prefabricated, off-the-shelf | 18 | $14.58 |
| L0984 | Protective body sock, prefabricated, off-the-shelf, each | 22 | $50.07 |
| L1000 | Cervical-thoracic-lumbar-sacral orthosis (ctlso) | 22 | $1,641.05 |
| L1005 | Tension based scoliosis orthosis and accessory pads | 21 | $2,910.76 |
| L1006 | Scoliosis orthosis, sagittal-coronal control provided by a... | 11 | $1,027.74 |
| L1010 | Addition to cervical-thoracic-lumbar-sacral orthosis | 22 | $58.40 |
| L1020 | Addition to ctlso or scoliosis orthosis, kyphosis pad | 22 | $76.97 |
| L1025 | Addition to ctlso or scoliosis orthosis, kyphosis pad | 21 | $123.03 |
| L1030 | Addition to ctlso or scoliosis orthosis, lumbar bolster pad | 22 | $59.29 |
| L1040 | Addition to ctlso or scoliosis orthosis | 22 | $74.51 |
| L1050 | Addition to ctlso or scoliosis orthosis, sternal pad | 22 | $72.63 |
| L1060 | Addition to ctlso or scoliosis orthosis, thoracic pad | 22 | $87.00 |
| L1070 | Addition to ctlso or scoliosis orthosis, trapezius sling | 22 | $82.01 |
| L1080 | Addition to ctlso or scoliosis orthosis, outrigger | 21 | $47.52 |
| L1085 | Addition to ctlso or scoliosis orthosis, outrigger | 21 | $134.63 |
| L1090 | Addition to ctlso or scoliosis orthosis, lumbar sling | 22 | $79.50 |
| L1100 | Addition to ctlso or scoliosis orthosis, ring flange | 20 | $128.21 |
| L1110 | Addition to ctlso or scoliosis orthosis, ring flange | 21 | $204.45 |
| L1120 | Addition to ctlso, scoliosis orthosis, cover for upright | 21 | $31.95 |
| L1200 | Thoracic-lumbar-sacral-orthosis (tlso) | 22 | $1,389.03 |
| L1210 | Addition to tlso, (low profile), lateral thoracic extension | 22 | $231.67 |
| L1220 | Addition to tlso, (low profile), anterior thoracic extension | 22 | $216.42 |
| L1230 | Addition to tlso, (low profile) | 22 | $525.90 |
| L1240 | Addition to tlso, (low profile), lumbar derotation pad | 22 | $72.33 |
| L1250 | Addition to tlso, (low profile), anterior asis pad | 22 | $63.03 |
| L1260 | Addition to tlso, (low profile) | 22 | $71.53 |
| L1270 | Addition to tlso, (low profile), abdominal pad | 22 | $70.33 |
| L1280 | Addition to tlso, (low profile), rib gusset (elastic), each | 22 | $75.97 |
| L1290 | Addition to tlso, (low profile), lateral trochanteric pad | 22 | $67.96 |
| L1300 | Other scoliosis procedure | 22 | $1,566.24 |
| L1310 | Other scoliosis procedure, post-operative body jacket | 21 | $1,630.18 |
| L1600 | Hip orthosis, abduction control of hip joints, flexible | 22 | $105.97 |
| L1610 | Hip orthosis, abduction control of hip joints, flexible, | 21 | $39.56 |
| L1620 | Hip orthosis, abduction control of hip joints, flexible, | 22 | $113.55 |
| L1630 | Hip orthosis, abduction control of hip joints | 22 | $143.69 |
| L1640 | Hip orthosis, abduction control of hip joints, static | 22 | $423.70 |
| L1650 | Hip orthosis, abduction control of hip joints, static | 22 | $193.10 |
| L1652 | Hip orthosis, bilateral thigh cuffs with adjustable abductor... | 22 | $323.96 |
| L1653 | Hip orthosis, bilateral thigh cuffs with adjustable abductor... | 12 | $335.34 |
| L1660 | Hip orthosis, abduction control of hip joints, static | 22 | $140.77 |
| L1680 | Hip orthosis, abduction control of hip joints, dynamic | 22 | $1,008.08 |
| L1681 | Hip orthosis, bilateral hip joints and thigh cuffs | 9 | $2,242.96 |
| L1685 | Hip orthosis, abduction control of hip joint | 22 | $984.14 |
| L1686 | Hip orthosis, abduction control of hip joint | 22 | $804.81 |
| L1690 | Combination, bilateral, lumbo-sacral, hip | 22 | $1,636.20 |
| L1700 | Legg perthes orthosis, (toronto type), custom fabricated | 22 | $1,384.66 |
| L1710 | Legg perthes orthosis, (newington type), custom fabricated | 22 | $1,616.49 |
| L1720 | Legg perthes orthosis, trilateral, (tachdijan type) | 22 | $1,103.58 |
| L1730 | Legg perthes orthosis, (scottish rite type) | 22 | $905.24 |
| L1755 | Legg perthes orthosis, (patten bottom type) | 22 | $1,339.26 |
| L1810 | Knee orthosis, elastic with joints | 21 | $93.62 |
| L1812 | Knee orthosis, elastic with joints, prefabricated | 20 | $65.28 |
| L1820 | Knee orthosis, elastic with condylar pads and joints | 22 | $123.74 |
| L1821 | Knee orthosis, elastic with condylar pads and joints | 11 | $129.24 |
| L1830 | Knee orthosis, immobilizer, canvas longitudinal | 21 | $54.12 |
| L1831 | Knee orthosis, locking knee joint(s), positional orthosis | 20 | $267.47 |
| L1832 | Knee orthosis, adjustable knee joints | 20 | $602.42 |
| L1833 | Knee orthosis, adjustable knee joints | 20 | $472.10 |
| L1834 | Knee orthosis, without knee joint, rigid, custom fabricated | 21 | $705.28 |
| L1836 | Knee orthosis, rigid, without joint(s) | 21 | $92.10 |
| L1840 | Knee orthosis, derotation, medial-lateral | 21 | $832.41 |
| L1843 | Knee orthosis, single upright, thigh and calf | 21 | $765.03 |
| L1844 | Knee orthosis, single upright, thigh and calf | 20 | $1,400.19 |
| L1845 | Knee orthosis, double upright, thigh and calf | 21 | $751.30 |
| L1846 | Knee orthosis, double upright, thigh and calf | 21 | $1,064.06 |
| L1847 | Knee orthosis, double upright with adjustable joint | 21 | $518.52 |
| L1848 | Knee orthosis, double upright with adjustable joint | 19 | $482.94 |
| L1850 | Knee orthosis, swedish type, prefabricated, off-the-shelf | 21 | $189.35 |
| L1851 | Knee orthosis (ko), single upright, thigh and calf | 20 | $608.65 |
| L1852 | Knee orthosis (ko), double upright, thigh and calf | 20 | $560.62 |
| L1860 | Knee orthosis, modification of supracondylar prosthetic... | 21 | $1,048.11 |
| L1900 | Ankle foot orthosis, spring wire | 21 | $256.86 |
| L1902 | Ankle orthosis, ankle gauntlet or similar | 20 | $66.38 |
| L1904 | Ankle orthosis, ankle gauntlet or similar | 20 | $414.97 |
| L1906 | Ankle foot orthosis, multiligamentous ankle support | 21 | $102.27 |
| L1907 | Ankle orthosis, supramalleolar with straps | 21 | $507.27 |
| L1910 | Ankle foot orthosis, posterior, single bar | 20 | $259.26 |
| L1920 | Ankle foot orthosis, single upright with static or... | 21 | $300.84 |
| L1930 | Ankle foot orthosis, plastic or other material | 21 | $203.60 |
| L1932 | Ankle foot orthosis, rigid anterior tibial section | 21 | $811.51 |
| L1933 | Ankle foot orthosis, rigid anterior tibial section | 12 | $884.97 |
| L1940 | Ankle foot orthosis, plastic or other material | 21 | $458.83 |
| L1945 | Ankle foot orthosis, plastic, rigid anterior tibial section | 21 | $778.58 |
| L1950 | Ankle foot orthosis, spiral, | 21 | $747.28 |
| L1951 | Ankle foot orthosis, spiral, | 21 | $762.65 |
| L1952 | Ankle foot orthosis, spiral, | 11 | $856.26 |
| L1960 | Ankle foot orthosis, posterior solid ankle, plastic | 21 | $546.90 |
| L1970 | Ankle foot orthosis, plastic with ankle joint | 21 | $638.85 |
| L1971 | Ankle foot orthosis, plastic or other material with ankle... | 20 | $424.13 |
| L1980 | Ankle foot orthosis, single upright free plantar... | 21 | $331.37 |
| L1990 | Ankle foot orthosis, double upright free plantar... | 21 | $424.98 |
| L2000 | Knee ankle foot orthosis, single upright, free knee | 21 | $920.01 |
| L2005 | Knee ankle foot orthosis, any material | 20 | $3,792.56 |
| L2006 | Knee ankle foot device, any material | 7 | $33,460.54 |
| L2010 | Knee ankle foot orthosis, single upright, free ankle | 21 | $793.53 |
| L2020 | Knee ankle foot orthosis, double upright, free ankle | 21 | $1,002.20 |
| L2030 | Knee ankle foot orthosis, double upright, free ankle | 21 | $985.08 |
| L2034 | Knee ankle foot orthosis, full plastic, single upright | 21 | $1,833.61 |
| L2035 | Knee ankle foot orthosis, full plastic, static | 21 | $157.55 |
| L2036 | Knee ankle foot orthosis, full plastic, double upright | 21 | $1,686.04 |
| L2037 | Knee ankle foot orthosis, full plastic, single upright | 20 | $1,590.71 |
| L2038 | Knee ankle foot orthosis, full plastic | 20 | $1,257.39 |
| L2040 | Hip knee ankle foot orthosis, torsion control | 21 | $170.93 |
| L2050 | Hip knee ankle foot orthosis, torsion control | 21 | $417.26 |
| L2060 | Hip knee ankle foot orthosis, torsion control | 21 | $494.47 |
| L2070 | Hip knee ankle foot orthosis, torsion control | 21 | $121.20 |
| L2080 | Hip knee ankle foot orthosis, torsion control | 21 | $339.39 |
| L2090 | Hip knee ankle foot orthosis, torsion control | 21 | $428.30 |
| L2106 | Ankle foot orthosis, fracture orthosis | 21 | $605.28 |
| L2108 | Ankle foot orthosis, fracture orthosis | 21 | $1,034.96 |
| L2112 | Ankle foot orthosis, fracture orthosis | 21 | $458.15 |
| L2114 | Ankle foot orthosis, fracture orthosis | 21 | $529.49 |
| L2116 | Ankle foot orthosis, fracture orthosis | 21 | $614.83 |
| L2126 | Knee ankle foot orthosis, fracture orthosis | 20 | $1,024.59 |
| L2128 | Knee ankle foot orthosis, fracture orthosis | 21 | $1,458.13 |
| L2132 | Kafo, fracture orthosis, femoral fracture cast orthosis | 20 | $750.13 |
| L2134 | Kafo, fracture orthosis, femoral fracture cast orthosis | 20 | $818.11 |
| L2136 | Kafo, fracture orthosis, femoral fracture cast orthosis | 21 | $1,021.36 |
| L2180 | Addition to lower extremity fracture orthosis | 22 | $98.99 |
| L2182 | Addition to lower extremity fracture orthosis | 22 | $73.37 |
| L2184 | Addition to lower extremity fracture orthosis | 22 | $105.26 |
| L2186 | Addition to lower extremity fracture orthosis | 22 | $134.84 |
| L2188 | Addition to lower extremity fracture orthosis | 21 | $288.33 |
| L2190 | Addition to lower extremity fracture orthosis, waist belt | 21 | $75.42 |
| L2192 | Addition to lower extremity fracture orthosis, hip joint | 21 | $302.76 |
| L2200 | Addition to lower extremity, limited ankle motion | 22 | $45.16 |
| L2210 | Addition to lower extremity, dorsiflexion assist | 22 | $58.06 |
| L2220 | Addition to lower extremity | 22 | $73.82 |
| L2221 | Addition to lower extremity orthosis, ankle system | 7 | $1,689.87 |
| L2230 | Addition to lower extremity | 22 | $64.29 |
| L2232 | Addition to lower extremity orthosis | 19 | $89.72 |
| L2240 | Addition to lower extremity | 22 | $66.98 |
| L2250 | Addition to lower extremity, foot plate | 22 | $294.58 |
| L2260 | Addition to lower extremity, reinforced solid stirrup | 22 | $171.80 |
| L2265 | Addition to lower extremity, long tongue stirrup | 21 | $94.73 |
| L2270 | Addition to lower extremity, varus/valgus correction | 21 | $48.61 |
| L2275 | Addition to lower extremity, varus/valgus correction | 21 | $117.47 |
| L2280 | Addition to lower extremity, molded inner boot | 22 | $376.90 |
| L2300 | Addition to lower extremity, abduction bar | 21 | $239.35 |
| L2310 | Addition to lower extremity, abduction bar-straight | 22 | $104.54 |
| L2320 | Addition to lower extremity, non-molded lacer | 22 | $199.54 |
| L2330 | Addition to lower extremity, lacer molded to patient model | 22 | $378.99 |
| L2335 | Addition to lower extremity, anterior swing band | 22 | $184.67 |
| L2340 | Addition to lower extremity, pre-tibial shell | 21 | $390.75 |
| L2350 | Addition to lower extremity, prosthetic type, (bk) socket | 22 | $815.14 |
| L2360 | Addition to lower extremity, extended steel shank | 22 | $46.86 |
| L2370 | Addition to lower extremity, patten bottom | 22 | $247.83 |
| L2375 | Addition to lower extremity, torsion control | 22 | $96.84 |
| L2380 | Addition to lower extremity, torsion control | 21 | $108.24 |
| L2385 | Addition to lower extremity, straight knee joint | 21 | $115.68 |
| L2387 | Addition to lower extremity, polycentric knee joint | 20 | $168.32 |
| L2390 | Addition to lower extremity, offset knee joint, each joint | 21 | $93.86 |
| L2395 | Addition to lower extremity, offset knee joint, heavy duty | 21 | $129.94 |
| L2397 | Addition to lower extremity orthosis, suspension sleeve | 21 | $101.55 |
| L2405 | Addition to knee joint, drop lock, each | 22 | $73.77 |
| L2415 | Addition to knee lock with integrated release mechanism | 22 | $109.91 |
| L2425 | Addition to knee joint | 22 | $126.48 |
| L2430 | Addition to knee joint | 21 | $129.23 |
| L2492 | Addition to knee joint, lift loop for drop lock ring | 22 | $100.65 |
| L2500 | Addition to lower extremity, thigh/weight bearing | 22 | $265.02 |
| L2510 | Addition to lower extremity, thigh/weight bearing | 22 | $696.15 |
| L2520 | Addition to lower extremity, thigh/weight bearing | 22 | $454.52 |
| L2525 | Addition to lower extremity, thigh/weight bearing | 21 | $1,120.69 |
| L2526 | Addition to lower extremity, thigh/weight bearing | 21 | $622.31 |
| L2530 | Addition to lower extremity, thigh-weight bearing, lacer | 22 | $217.95 |
| L2540 | Addition to lower extremity, thigh/weight bearing, lacer | 22 | $362.91 |
| L2550 | Addition to lower extremity, thigh/weight bearing | 22 | $282.07 |
| L2570 | Addition to lower extremity, pelvic control, hip joint | 21 | $405.03 |
| L2580 | Addition to lower extremity, pelvic control, pelvic sling | 22 | $411.50 |
| L2600 | Addition to lower extremity, pelvic control, hip joint | 22 | $185.10 |
| L2610 | Addition to lower extremity, pelvic control, hip joint | 22 | $214.48 |
| L2620 | Addition to lower extremity, pelvic control, hip joint | 22 | $242.28 |
| L2622 | Addition to lower extremity, pelvic control, hip joint | 21 | $264.02 |
| L2624 | Addition to lower extremity, pelvic control, hip joint | 21 | $285.99 |
| L2627 | Addition to lower extremity, pelvic control, plastic | 21 | $1,650.44 |
| L2628 | Addition to lower extremity, pelvic control, metal frame | 21 | $1,505.06 |
| L2630 | Addition to lower extremity, pelvic control, band and belt | 22 | $218.24 |
| L2640 | Addition to lower extremity, pelvic control, band and belt | 22 | $285.57 |
| L2650 | Addition to lower extremity, pelvic and thoracic control | 22 | $103.28 |
| L2660 | Addition to lower extremity, thoracic control, thoracic band | 22 | $157.39 |
| L2670 | Addition to lower extremity, thoracic control | 22 | $148.89 |
| L2680 | Addition to lower extremity, thoracic control | 22 | $133.95 |
| L2750 | Addition to lower extremity orthosis | 21 | $79.14 |
| L2755 | Addition to lower extremity orthosis, high strength | 20 | $110.53 |
| L2760 | Addition to lower extremity orthosis, extension | 22 | $53.48 |
| L2768 | Orthotic side bar disconnect device, per bar | 21 | $118.48 |
| L2780 | Addition to lower extremity orthosis, non-corrosive finish | 21 | $60.60 |
| L2785 | Addition to lower extremity orthosis, drop lock retainer | 22 | $28.49 |
| L2795 | Addition to lower extremity orthosis, knee control | 22 | $70.93 |
| L2800 | Addition to lower extremity orthosis, knee control | 22 | $88.63 |
| L2810 | Addition to lower extremity orthosis, knee control | 22 | $65.24 |
| L2820 | Addition to lower extremity orthosis | 21 | $80.22 |
| L2830 | Addition to lower extremity orthosis | 22 | $81.93 |
| L2840 | Addition to lower extremity orthosis, tibial length sock | 21 | $38.54 |
| L2850 | Addition to lower extremity orthosis, femoral length sock | 21 | $54.94 |
| L2861 | Addition to lower extremity joint, knee or ankle | 6 | $271.25 |
| L3000 | Foot, insert, removable, molded to patient model | 22 | $266.43 |
| L3001 | Foot, insert, removable, molded to patient model, spenco | 18 | $117.74 |
| L3002 | Foot, insert, removable, molded to patient model | 19 | $137.67 |
| L3003 | Foot, insert, removable, molded to patient model | 17 | $164.89 |
| L3010 | Foot, insert, removable, molded to patient model | 19 | $146.33 |
| L3020 | Foot, insert, removable, molded to patient model | 20 | $174.79 |
| L3030 | Foot, insert, removable, formed to patient foot, each | 20 | $69.10 |
| L3031 | Foot, insert/plate, removable | 16 | $121.41 |
| L3040 | Foot, arch support, removable, premolded, longitudinal, each | 18 | $42.35 |
| L3050 | Foot, arch support, removable, premolded, metatarsal, each | 18 | $42.78 |
| L3060 | Foot, arch support, removable, premolded | 17 | $66.98 |
| L3070 | Foot, arch support, non-removable attached to shoe | 16 | $28.90 |
| L3080 | Foot, arch support, non-removable attached to shoe | 15 | $28.88 |
| L3090 | Foot, arch support, non-removable attached to shoe | 14 | $37.83 |
| L3100 | Hallus-valgus night dynamic splint, prefabricated | 19 | $36.30 |
| L3140 | Foot, abduction rotation bar, including shoes | 22 | $73.11 |
| L3150 | Foot, abduction rotation bar, without shoes | 21 | $73.38 |
| L3160 | Orthotics and prosthetics | 8 | $63.29 |
| L3170 | Foot, plastic, silicone or equal, heel stabilizer | 20 | $41.78 |
| L3201 | Orthopedic shoe, oxford with supinator or pronator, infant | 18 | $45.66 |
| L3202 | Orthopedic shoe, oxford with supinator or pronator, child | 17 | $46.07 |
| L3203 | Orthopedic shoe, oxford with supinator or pronator, junior | 17 | $42.68 |
| L3204 | Orthopedic shoe, hightop with supinator or pronator, infant | 16 | $36.73 |
| L3206 | Orthopedic shoe, hightop with supinator or pronator, child | 16 | $41.47 |
| L3207 | Orthopedic shoe, hightop with supinator or pronator, junior | 16 | $42.81 |
| L3208 | Surgical boot, each, infant | 16 | $26.34 |
| L3209 | Surgical boot, each, child | 16 | $31.79 |
| L3211 | Surgical boot, each, junior | 15 | $30.41 |
| L3212 | Benesch boot, pair, infant | 14 | $55.36 |
| L3213 | Benesch boot, pair, child | 14 | $57.35 |
| L3214 | Benesch boot, pair, junior | 14 | $58.77 |
| L3215 | Orthopedic footwear, ladies shoe, oxford, each | 17 | $73.85 |
| L3216 | Orthopedic footwear, ladies shoe, depth inlay, each | 16 | $72.26 |
| L3217 | Orthopedic footwear, ladies shoe, hightop, depth inlay, each | 15 | $80.56 |
| L3219 | Orthopedic footwear, mens shoe, oxford, each | 17 | $81.62 |
| L3221 | Orthopedic footwear, mens shoe, depth inlay, each | 16 | $74.43 |
| L3222 | Orthopedic footwear, mens shoe, hightop, depth inlay, each | 17 | $93.45 |
| L3224 | Orthopedic footwear, woman's shoe, oxford | 18 | $58.35 |
| L3225 | Orthopedic footwear, man's shoe, oxford | 18 | $66.88 |
| L3230 | Orthotics and prosthetics | 15 | $171.02 |
| L3250 | Orthopedic footwear, custom molded shoe | 15 | $243.65 |
| L3251 | Foot, shoe molded to patient model, silicone shoe, each | 12 | $208.57 |
| L3252 | Foot, shoe molded to patient model, plastazote (or similar) | 14 | $165.73 |
| L3253 | Foot, molded shoe plastazote (or similar) custom fitted | 14 | $69.24 |
| L3254 | Non-standard size or width | 9 | $21.28 |
| L3255 | Non-standard size or length | 9 | $20.81 |
| L3257 | Orthopedic footwear, additional charge for split size | 13 | $45.39 |
| L3260 | Surgical boot/shoe, each | 15 | $44.71 |
| L3265 | Plastazote sandal, each | 11 | $37.83 |
| L3300 | Lift, elevation, heel, tapered to metatarsals, per inch | 19 | $46.48 |
| L3310 | Lift, elevation, heel and sole, neoprene, per inch | 21 | $72.59 |
| L3320 | Lift, elevation, heel and sole, cork, per inch | 18 | $69.40 |
| L3330 | Lift, elevation, metal extension (skate) | 19 | $513.94 |
| L3332 | Lift, elevation, inside shoe, tapered, up to one-half inch | 20 | $62.41 |
| L3334 | Lift, elevation, heel, per inch | 21 | $34.63 |
| L3340 | Heel wedge, sach | 20 | $77.46 |
| L3350 | Heel wedge | 20 | $20.13 |
| L3360 | Sole wedge, outside sole | 20 | $31.34 |
| L3370 | Sole wedge, between sole | 19 | $42.30 |
| L3380 | Clubfoot wedge | 19 | $45.05 |
| L3390 | Outflare wedge | 19 | $45.05 |
| L3400 | Metatarsal bar wedge, rocker | 21 | $35.29 |
| L3410 | Metatarsal bar wedge, between sole | 21 | $84.30 |
| L3420 | Full sole and heel wedge, between sole | 20 | $49.71 |
| L3430 | Heel, counter, plastic reinforced | 20 | $145.64 |
| L3440 | Heel, counter, leather reinforced | 19 | $69.30 |
| L3450 | Heel, sach cushion type | 19 | $95.84 |
| L3455 | Heel, new leather, standard | 18 | $36.99 |
| L3460 | Heel, new rubber, standard | 19 | $28.81 |
| L3465 | Heel, thomas with wedge | 19 | $53.16 |
| L3470 | Heel, thomas extended to ball | 19 | $56.58 |
| L3480 | Heel, pad and depression for spur | 17 | $52.32 |
| L3485 | Orthotics and prosthetics | 14 | $19.96 |
| L3500 | Orthopedic shoe addition, insole, leather | 17 | $26.59 |
| L3510 | Orthopedic shoe addition, insole, rubber | 17 | $26.59 |
| L3520 | Orthopedic shoe addition, insole, felt covered with leather | 18 | $28.90 |
| L3530 | Orthopedic shoe addition, sole, half | 18 | $29.71 |
| L3540 | Orthopedic shoe addition, sole, full | 18 | $46.23 |
| L3550 | Orthopedic shoe addition, toe tap standard | 18 | $8.34 |
| L3560 | Orthopedic shoe addition, toe tap, horseshoe | 18 | $21.18 |
| L3570 | Orthopedic shoe addition, special extension to instep | 19 | $77.41 |
| L3580 | Orthopedic shoe addition, convert instep to velcro closure | 20 | $56.69 |
| L3590 | Orthopedic shoe addition | 19 | $48.59 |
| L3595 | Orthopedic shoe addition, march bar | 19 | $38.14 |
| L3600 | Transfer of an orthosis from one shoe to another | 21 | $64.09 |
| L3610 | Transfer of an orthosis from one shoe to another | 21 | $84.36 |
| L3620 | Transfer of an orthosis from one shoe to another | 22 | $66.45 |
| L3630 | Transfer of an orthosis from one shoe to another | 21 | $84.36 |
| L3640 | Transfer of an orthosis from one shoe to another | 19 | $36.30 |
| L3650 | Shoulder orthosis, figure of eight design abduction... | 21 | $48.98 |
| L3660 | Shoulder orthosis, figure of eight design abduction... | 19 | $85.52 |
| L3670 | Shoulder orthosis, acromio/clavicular | 20 | $98.31 |
| L3671 | Shoulder orthosis, shoulder joint design, without joints | 18 | $755.41 |
| L3674 | Shoulder orthosis, abduction positioning (airplane design) | 17 | $962.68 |
| L3675 | Shoulder orthosis, vest type abduction restrainer | 20 | $138.33 |
| L3677 | Shoulder orthosis, shoulder joint design, without joints | 6 | $161.83 |
| L3702 | Elbow orthosis, without joints, may include soft interface | 19 | $239.00 |
| L3710 | Elbow orthosis, elastic with metal joints, prefabricated | 21 | $104.47 |
| L3720 | Elbow orthosis, double upright with forearm/arm cuffs | 21 | $565.52 |
| L3730 | Elbow orthosis, double upright with forearm/arm cuffs | 21 | $755.94 |
| L3740 | Elbow orthosis, double upright with forearm/arm cuffs | 21 | $950.19 |
| L3760 | Elbow orthosis (eo), with adjustable position locking... | 21 | $410.30 |
| L3761 | Elbow orthosis (eo), with adjustable position locking... | 20 | $431.94 |
| L3762 | Elbow orthosis, rigid, without joints | 21 | $88.22 |
| L3763 | Elbow wrist hand orthosis, rigid, without joints | 21 | $619.37 |
| L3764 | Elbow wrist hand orthosis | 20 | $727.19 |
| L3765 | Elbow wrist hand finger orthosis, rigid, without joints | 19 | $1,097.85 |
| L3766 | Elbow wrist hand finger orthosis | 20 | $1,138.28 |
| L3806 | Wrist hand finger orthosis | 17 | $388.93 |
| L3807 | Wrist hand finger orthosis, without joint(s) | 19 | $215.35 |
| L3808 | Wrist hand finger orthosis, rigid without joints | 20 | $302.86 |
| L3809 | Wrist hand finger orthosis, without joint(s), prefabricated | 20 | $192.54 |
| L3891 | Addition to upper extremity joint, wrist or elbow | 5 | $300.04 |
| L3900 | Wrist hand finger orthosis, dynamic flexor hinge | 21 | $1,140.37 |
| L3901 | Wrist hand finger orthosis, dynamic flexor hinge | 20 | $1,442.83 |
| L3904 | Wrist hand finger orthosis, external powered, electric | 18 | $2,592.86 |
| L3905 | Wrist hand orthosis, includes one or more nontorsion joints | 18 | $835.33 |
| L3906 | Wrist hand orthosis, without joints | 21 | $315.55 |
| L3908 | Wrist hand orthosis, wrist extension control cock-up | 21 | $49.84 |
| L3912 | Hand finger orthosis (hfo) | 21 | $81.60 |
| L3913 | Hand finger orthosis, without joints | 19 | $224.15 |
| L3915 | Wrist hand orthosis, includes one or more nontorsion... | 20 | $438.04 |
| L3916 | Wrist hand orthosis, includes one or more nontorsion... | 18 | $416.95 |
| L3917 | Hand orthosis, metacarpal fracture orthosis | 20 | $87.84 |
| L3918 | Hand orthosis, metacarpal fracture orthosis, prefabricated | 19 | $81.95 |
| L3919 | Hand orthosis, without joints, may include soft interface | 19 | $224.15 |
| L3921 | Hand finger orthosis | 18 | $266.72 |
| L3923 | Hand finger orthosis, without joints | 21 | $74.52 |
| L3924 | Hand finger orthosis, without joints | 20 | $67.80 |
| L3925 | Finger orthosis, proximal interphalangeal | 22 | $44.09 |
| L3927 | Finger orthosis, proximal interphalangeal | 18 | $29.49 |
| L3929 | Hand finger orthosis | 21 | $75.60 |
| L3930 | Hand finger orthosis | 18 | $67.13 |
| L3931 | Wrist hand finger orthosis | 21 | $158.08 |
| L3933 | Finger orthosis, without joints, may include soft interface | 20 | $175.03 |
| L3935 | Finger orthosis, nontorsion joint | 19 | $184.70 |
| L3960 | Shoulder elbow wrist hand orthosis, abduction positioning | 21 | $601.72 |
| L3961 | Shoulder elbow wrist hand orthosis, shoulder cap design | 18 | $1,390.94 |
| L3962 | Shoulder elbow wrist hand orthosis, abduction positioning | 20 | $611.78 |
| L3967 | Shoulder elbow wrist hand orthosis, abduction positioning | 18 | $1,662.95 |
| L3971 | Shoulder elbow wrist hand orthosis, shoulder cap design | 18 | $1,529.91 |
| L3973 | Shoulder elbow wrist hand orthosis, abduction positioning | 18 | $1,662.95 |
| L3975 | Shoulder elbow wrist hand finger orthosis | 18 | $1,408.48 |
| L3976 | Shoulder elbow wrist hand finger orthosis | 18 | $1,408.48 |
| L3977 | Shoulder elbow wrist hand finger orthosis | 18 | $1,578.54 |
| L3978 | Shoulder elbow wrist hand finger orthosis | 18 | $1,662.95 |
| L3980 | Upper extremity fracture orthosis, humeral, prefabricated | 22 | $269.75 |
| L3981 | Upper extremity fracture orthosis, humeral, prefabricated | 13 | $861.82 |
| L3982 | Upper extremity fracture orthosis, radius/ulnar | 22 | $320.08 |
| L3984 | Upper extremity fracture orthosis, wrist, prefabricated | 22 | $288.12 |
| L3995 | Addition to upper extremity orthosis, sock | 20 | $31.13 |
| L4000 | Replace girdle for spinal orthosis (ctlso or so) | 22 | $999.38 |
| L4002 | Replacement strap, any orthosis, includes all components | 12 | $16.44 |
| L4010 | Replace trilateral socket brim | 22 | $602.58 |
| L4020 | Replace quadrilateral socket brim, molded to patient model | 21 | $827.58 |
| L4030 | Replace quadrilateral socket brim, custom fitted | 21 | $493.14 |
| L4040 | Replace molded thigh lacer | 21 | $388.22 |
| L4045 | Replace non-molded thigh lacer | 22 | $271.40 |
| L4050 | Orthotics and prosthetics | 22 | $386.79 |
| L4055 | Replace non-molded calf lacer | 22 | $214.85 |
| L4060 | Replace high roll cuff | 22 | $272.54 |
| L4070 | Replace proximal and distal upright for kafo | 22 | $239.14 |
| L4080 | Replace metal bands kafo, proximal thigh | 22 | $86.69 |
| L4090 | Replace metal bands kafo-afo, calf or distal thigh | 22 | $75.47 |
| L4100 | Replace leather cuff kafo, proximal thigh | 21 | $92.36 |
| L4110 | Replace leather cuff kafo-afo, calf or distal thigh | 22 | $70.94 |
| L4130 | Replace pretibial shell | 22 | $435.33 |
| L4205 | Repair of orthotic device, labor component, per 15 minutes | 19 | $20.94 |
| L4210 | Repair of orthotic device, repair or replace minor parts | 10 | $39.76 |
| L4350 | Ankle control orthosis, stirrup style, rigid | 19 | $78.44 |
| L4360 | Walking boot, pneumatic and/or vacuum | 20 | $235.54 |
| L4361 | Walking boot, pneumatic and/or vacuum | 19 | $231.06 |
| L4370 | Pneumatic full leg splint, prefabricated, off-the-shelf | 19 | $163.30 |
| L4386 | Walking boot, non-pneumatic, with or without joints | 20 | $143.57 |
| L4387 | Walking boot, non-pneumatic, with or without joints | 19 | $130.86 |
| L4392 | Replacement, soft interface material, static afo | 18 | $20.57 |
| L4394 | Replace soft interface material, foot drop splint | 18 | $15.73 |
| L4396 | Static or dynamic ankle foot orthosis | 22 | $144.82 |
| L4397 | Static or dynamic ankle foot orthosis | 18 | $130.97 |
| L4398 | Foot drop splint, recumbent positioning device | 21 | $70.24 |
| L4631 | Ankle foot orthosis, walking boot type | 20 | $1,378.26 |
| L5000 | Partial foot, shoe insert with longitudinal arch, toe filler | 22 | $444.75 |
| L5010 | Partial foot, molded socket, ankle height, with toe filler | 22 | $1,075.55 |
| L5020 | Partial foot, molded socket, tibial tubercle height | 22 | $1,711.70 |
| L5050 | Ankle, symes, molded socket, sach foot | 21 | $2,091.57 |
| L5060 | Ankle, symes, metal frame, molded leather socket | 21 | $2,458.54 |
| L5100 | Below knee, molded socket, shin, sach foot | 21 | $2,041.52 |
| L5105 | Below knee, plastic socket, joints and thigh lacer | 22 | $2,846.18 |
| L5150 | Knee disarticulation (or through knee), molded socket | 22 | $2,817.63 |
| L5160 | Knee disarticulation (or through knee), molded socket | 22 | $3,398.84 |
| L5200 | Above knee, molded socket | 22 | $2,832.69 |
| L5210 | Above knee, short prosthesis, no knee joint ('stubbies') | 22 | $2,361.26 |
| L5220 | Above knee, short prosthesis, no knee joint ('stubbies') | 22 | $2,394.88 |
| L5230 | Above knee, for proximal femoral focal deficiency | 22 | $3,211.72 |
| L5250 | Hip disarticulation, canadian type; molded socket | 22 | $4,198.94 |
| L5270 | Hip disarticulation, tilt table type; molded socket | 21 | $4,745.60 |
| L5280 | Hemipelvectomy, canadian type; molded socket, hip joint | 22 | $4,396.70 |
| L5301 | Below knee, molded socket, shin, sach foot | 21 | $2,186.06 |
| L5312 | Knee disarticulation (or through knee), molded socket | 19 | $3,559.33 |
| L5321 | Above knee, molded socket, open end, sach foot | 21 | $3,168.76 |
| L5331 | Hip disarticulation, canadian type, molded socket | 22 | $4,623.51 |
| L5341 | Hemipelvectomy, canadian type, molded socket | 22 | $4,865.79 |
| L5400 | Immediate post surgical or early fitting | 21 | $1,082.29 |
| L5410 | Immediate post surgical or early fitting | 20 | $370.99 |
| L5420 | Immediate post surgical or early fitting | 20 | $1,314.47 |
| L5430 | Immediate post surgical or early fitting | 19 | $463.90 |
| L5450 | Immediate post surgical or early fitting | 20 | $401.01 |
| L5460 | Immediate post surgical or early fitting | 20 | $490.17 |
| L5500 | Initial, below knee 'ptb' type socket, non-alignable system | 21 | $1,185.07 |
| L5505 | Initial, above knee - knee disarticulation | 21 | $1,604.89 |
| L5510 | Preparatory, below knee 'ptb' type socket | 21 | $1,313.44 |
| L5520 | Preparatory, below knee 'ptb' type socket | 21 | $1,359.06 |
| L5530 | Preparatory, below knee 'ptb' type socket | 22 | $1,736.89 |
| L5535 | Preparatory, below knee 'ptb' type socket | 22 | $1,569.50 |
| L5540 | Preparatory, below knee 'ptb' type socket | 22 | $1,676.89 |
| L5560 | Preparatory, above knee- knee disarticulation | 22 | $1,868.18 |
| L5570 | Preparatory, above knee - knee disarticulation | 21 | $2,064.54 |
| L5580 | Preparatory, above knee - knee disarticulation ischial level... | 22 | $2,211.05 |
| L5585 | Preparatory, above knee - knee disarticulation | 21 | $2,307.16 |
| L5590 | Preparatory, above knee - knee disarticulation ischial level... | 21 | $2,293.95 |
| L5595 | Preparatory, hip disarticulation-hemipelvectomy, pylon | 22 | $3,592.20 |
| L5600 | Preparatory, hip disarticulation-hemipelvectomy, pylon | 22 | $4,074.02 |
| L5610 | Addition to lower extremity, endoskeletal system | 21 | $1,910.37 |
| L5611 | Addition to lower extremity, endoskeletal system | 22 | $1,403.78 |
| L5613 | Addition to lower extremity, endoskeletal system | 22 | $2,237.56 |
| L5614 | Addition to lower extremity, exoskeletal system | 19 | $1,539.04 |
| L5615 | Addition, endoskeletal knee-shin system | 11 | $6,372.75 |
| L5616 | Addition to lower extremity, endoskeletal system | 22 | $1,251.43 |
| L5617 | Addition to lower extremity | 20 | $477.98 |
| L5618 | Addition to lower extremity, test socket, symes | 22 | $245.82 |
| L5620 | Addition to lower extremity, test socket, below knee | 21 | $260.00 |
| L5622 | Addition to lower extremity, test socket | 22 | $350.00 |
| L5624 | Addition to lower extremity, test socket, above knee | 21 | $335.28 |
| L5626 | Addition to lower extremity, test socket | 22 | $405.70 |
| L5628 | Addition to lower extremity, test socket, hemipelvectomy | 22 | $429.78 |
| L5629 | Addition to lower extremity, below knee, acrylic socket | 21 | $288.62 |
| L5630 | Addition to lower extremity, symes type | 22 | $437.63 |
| L5631 | Addition to lower extremity | 21 | $401.22 |
| L5632 | Addition to lower extremity, symes type | 22 | $201.08 |
| L5634 | Addition to lower extremity, symes type, posterior opening | 21 | $306.38 |
| L5636 | Addition to lower extremity, symes type | 22 | $234.35 |
| L5637 | Addition to lower extremity, below knee, total contact | 21 | $273.94 |
| L5638 | Addition to lower extremity, below knee, leather socket | 21 | $501.77 |
| L5639 | Addition to lower extremity, below knee, wood socket | 22 | $1,014.99 |
| L5640 | Addition to lower extremity, knee disarticulation | 22 | $662.45 |
| L5642 | Addition to lower extremity, above knee, leather socket | 22 | $606.94 |
| L5643 | Addition to lower extremity, hip disarticulation | 22 | $1,430.90 |
| L5644 | Addition to lower extremity, above knee, wood socket | 21 | $535.09 |
| L5645 | Addition to lower extremity, below knee | 22 | $665.03 |
| L5646 | Addition to lower extremity, below knee, air, fluid | 22 | $498.32 |
| L5647 | Addition to lower extremity, below knee suction socket | 22 | $717.09 |
| L5648 | Addition to lower extremity, above knee, air, fluid | 22 | $600.03 |
| L5649 | Addition to lower extremity | 20 | $1,706.47 |
| L5650 | Additions to lower extremity, total contact | 21 | $472.54 |
| L5651 | Addition to lower extremity, above knee | 21 | $1,029.15 |
| L5652 | Addition to lower extremity, suction suspension | 21 | $390.00 |
| L5653 | Addition to lower extremity, knee disarticulation | 22 | $511.95 |
| L5654 | Addition to lower extremity, socket insert, symes, (kemblo | 22 | $279.89 |
| L5655 | Addition to lower extremity, socket insert, below knee | 21 | $245.87 |
| L5656 | Addition to lower extremity, socket insert | 22 | $374.14 |
| L5658 | Addition to lower extremity, socket insert, above knee | 21 | $335.45 |
| L5661 | Addition to lower extremity, socket insert | 21 | $492.91 |
| L5665 | Addition to lower extremity, socket insert, multi-durometer | 21 | $430.16 |
| L5666 | Addition to lower extremity, below knee, cuff suspension | 22 | $64.13 |
| L5668 | Addition to lower extremity, below knee | 21 | $90.21 |
| L5670 | Addition to lower extremity, below knee | 21 | $250.47 |
| L5671 | Addition to lower extremity | 21 | $457.51 |
| L5672 | Addition to lower extremity, below knee | 22 | $266.79 |
| L5673 | Addition to lower extremity, below knee/above knee | 21 | $659.09 |
| L5676 | Additions to lower extremity, below knee, knee joints | 22 | $319.18 |
| L5677 | Additions to lower extremity, below knee, knee joints | 21 | $399.37 |
| L5678 | Additions to lower extremity, below knee, joint covers, pair | 22 | $35.74 |
| L5679 | Addition to lower extremity, below knee/above knee | 21 | $549.24 |
| L5680 | Addition to lower extremity, below knee, thigh lacer | 22 | $275.55 |
| L5681 | Addition to lower extremity, below knee/above knee | 21 | $1,188.16 |
| L5682 | Addition to lower extremity, below knee, thigh lacer | 22 | $539.16 |
| L5683 | Addition to lower extremity, below knee/above knee | 20 | $1,189.84 |
| L5684 | Addition to lower extremity, below knee, fork strap | 22 | $40.62 |
| L5685 | Addition to lower extremity prosthesis, below knee | 22 | $111.45 |
| L5686 | Addition to lower extremity, below knee, back check | 22 | $52.41 |
| L5688 | Addition to lower extremity, below knee, waist belt, webbing | 22 | $55.67 |
| L5690 | Addition to lower extremity, below knee, waist belt | 22 | $84.30 |
| L5692 | Addition to lower extremity, above knee | 22 | $117.04 |
| L5694 | Addition to lower extremity, above knee | 22 | $159.80 |
| L5695 | Addition to lower extremity, above knee, pelvic control | 21 | $147.74 |
| L5696 | Addition to lower extremity | 22 | $169.33 |
| L5697 | Addition to lower extremity | 22 | $66.90 |
| L5698 | Addition to lower extremity | 21 | $104.33 |
| L5699 | All lower extremity prostheses, shoulder harness | 22 | $167.52 |
| L5700 | Replacement, socket, below knee, molded to patient model | 21 | $2,498.94 |
| L5701 | Replacement, socket, above knee/knee disarticulation | 21 | $3,100.16 |
| L5702 | Replacement, socket, hip disarticulation | 22 | $4,018.22 |
| L5703 | Ankle, symes, molded to patient model | 20 | $2,136.44 |
| L5704 | Custom shaped protective cover, below knee | 21 | $487.43 |
| L5705 | Custom shaped protective cover, above knee | 21 | $885.51 |
| L5706 | Custom shaped protective cover, knee disarticulation | 22 | $925.19 |
| L5707 | Custom shaped protective cover, hip disarticulation | 21 | $1,293.36 |
| L5710 | Addition, exoskeletal knee-shin system, single axis | 22 | $310.80 |
| L5711 | Additions exoskeletal knee-shin system, single axis | 21 | $415.39 |
| L5712 | Addition, exoskeletal knee-shin system, single axis | 22 | $362.73 |
| L5714 | Addition, exoskeletal knee-shin system, single axis | 22 | $378.35 |
| L5716 | Addition, exoskeletal knee-shin system, polycentric | 22 | $671.57 |
| L5718 | Addition, exoskeletal knee-shin system, polycentric | 22 | $777.13 |
| L5722 | Addition, exoskeletal knee-shin system, single axis | 22 | $825.45 |
| L5724 | Addition, exoskeletal knee-shin system, single axis | 22 | $1,335.44 |
| L5726 | Addition, exoskeletal knee-shin system, single axis | 22 | $1,732.06 |
| L5728 | Addition, exoskeletal knee-shin system, single axis | 22 | $2,128.36 |
| L5780 | Addition, exoskeletal knee-shin system, single axis | 22 | $1,017.31 |
| L5781 | Addition to lower limb prosthesis, vacuum pump | 17 | $3,771.58 |
| L5782 | Addition to lower limb prosthesis, vacuum pump | 13 | $4,052.85 |
| L5783 | Addition to lower extremity, user adjustable, mechanical | 11 | $2,442.89 |
| L5785 | Addition, exoskeletal system, below knee | 20 | $457.63 |
| L5790 | Addition, exoskeletal system, above knee | 20 | $641.79 |
| L5795 | Addition, exoskeletal system, hip disarticulation | 21 | $971.30 |
| L5810 | Addition, endoskeletal knee-shin system, single axis | 22 | $408.12 |
| L5811 | Addition, endoskeletal knee-shin system, single axis | 20 | $624.44 |
| L5812 | Addition, endoskeletal knee-shin system, single axis | 22 | $474.02 |
| L5814 | Addition, endoskeletal knee-shin system, polycentric | 21 | $3,172.65 |
| L5816 | Addition, endoskeletal knee-shin system, polycentric | 22 | $749.64 |
| L5818 | Addition, endoskeletal knee-shin system, polycentric | 22 | $867.58 |
| L5822 | Addition, endoskeletal knee-shin system, single axis | 21 | $1,596.00 |
| L5824 | Addition, endoskeletal knee-shin system, single axis | 22 | $1,461.86 |
| L5826 | Addition, endoskeletal knee-shin system, single axis | 19 | $2,848.26 |
| L5827 | Endoskeletal knee-shin system, single axis | 10 | $7,014.72 |
| L5828 | Addition, endoskeletal knee-shin system, single axis | 22 | $2,633.10 |
| L5830 | Addition, endoskeletal knee-shin system, single axis | 22 | $1,693.17 |
| L5840 | Addition, endoskeletal knee/shin system | 20 | $3,253.18 |
| L5841 | Addition, endoskeletal knee-shin system, polycentric | 9 | $2,759.19 |
| L5845 | Addition, endoskeletal, knee-shin system | 21 | $1,531.15 |
| L5848 | Addition to endoskeletal knee-shin system | 21 | $974.06 |
| L5850 | Addition, endoskeletal system | 21 | $114.88 |
| L5855 | Addition, endoskeletal system, hip disarticulation | 21 | $279.79 |
| L5856 | Addition to lower extremity prosthesis | 16 | $22,688.38 |
| L5857 | Addition to lower extremity prosthesis | 16 | $7,765.45 |
| L5858 | Addition to lower extremity prosthesis | 15 | $17,518.80 |
| L5859 | Addition to lower extremity prosthesis | 9 | $14,493.42 |
| L5910 | Addition, endoskeletal system, below knee, alignable system | 21 | $328.11 |
| L5920 | Addition, endoskeletal system | 21 | $472.81 |
| L5925 | Addition, endoskeletal system, above knee | 20 | $334.00 |
| L5926 | Addition to lower extremity prosthesis, endoskeletal | 13 | $606.42 |
| L5930 | Addition, endoskeletal system | 20 | $2,964.45 |
| L5940 | Addition, endoskeletal system, below knee | 21 | $454.43 |
| L5950 | Addition, endoskeletal system, above knee | 21 | $704.83 |
| L5960 | Addition, endoskeletal system, hip disarticulation | 22 | $951.12 |
| L5961 | Addition, endoskeletal system, polycentric hip joint | 12 | $4,682.56 |
| L5962 | Addition, endoskeletal system, below knee | 20 | $551.40 |
| L5964 | Addition, endoskeletal system, above knee | 20 | $930.26 |
| L5966 | Addition, endoskeletal system, hip disarticulation | 21 | $1,251.43 |
| L5968 | Addition to lower limb prosthesis | 21 | $3,246.71 |
| L5970 | All lower extremity prostheses, foot, external keel | 22 | $183.87 |
| L5971 | All lower extremity prosthesis, solid ankle cushion heel | 20 | $208.53 |
| L5972 | All lower extremity prostheses, foot, flexible keel | 21 | $360.71 |
| L5973 | Endoskeletal ankle foot system | 8 | $17,227.78 |
| L5974 | All lower extremity prostheses, foot, single axis ankle/foot | 21 | $207.42 |
| L5975 | All lower extremity prosthesis | 22 | $416.47 |
| L5976 | All lower extremity prostheses, energy storing foot | 21 | $515.11 |
| L5978 | All lower extremity prostheses, foot, multiaxial ankle/foot | 21 | $252.72 |
| L5979 | All lower extremity prosthesis, multi-axial ankle | 21 | $2,175.84 |
| L5980 | All lower extremity prostheses, flex foot system | 21 | $3,535.00 |
| L5981 | All lower extremity prostheses, flex-walk system or equal | 21 | $2,714.05 |
| L5982 | All exoskeletal lower extremity prostheses | 21 | $558.75 |
| L5984 | All endoskeletal lower extremity prosthesis | 21 | $506.76 |
| L5985 | All endoskeletal lower extremity prostheses | 22 | $248.71 |
| L5986 | All lower extremity prostheses, multi-axial rotation unit | 21 | $560.76 |
| L5987 | All lower extremity prosthesis | 20 | $6,098.68 |
| L5988 | Addition to lower limb prosthesis | 22 | $1,739.53 |
| L5990 | Addition to lower extremity prosthesis | 19 | $1,654.66 |
| L5991 | Addition to lower extremity prostheses | 7 | $10,129.00 |
| L5992 | All lower extremity prosthesis | 10 | $114.40 |
| L6000 | Partial hand, thumb remaining | 11 | $1,127.52 |
| L6010 | Partial hand, little and/or ring finger remaining | 11 | $1,254.75 |
| L6020 | Partial hand, no finger remaining | 11 | $1,201.41 |
| L6026 | Transcarpal/metacarpal or partial hand disarticulation... | 14 | $4,557.25 |
| L6028 | Partial hand, finger | 7 | $1,693.00 |
| L6029 | Upper extremity addition, test socket/interface | 5 | $336.70 |
| L6030 | Upper extremity addition, external frame | 5 | $626.77 |
| L6031 | Replacement socket/interface | 5 | $1,535.20 |
| L6032 | Addition to upper extremity prosthesis | 5 | $354.53 |
| L6033 | Addition to upper extremity prosthesis | 5 | $442.58 |
| L6034 | Partial hand, finger | 5 | $457.50 |
| L6037 | Immediate post-surgical or early fitting | 5 | $1,360.55 |
| L6038 | Addition to single prosthetic digit or thumb, mechanical | 5 | $295.87 |
| L6039 | Passive prosthetic digit or thumb prosthesis not including... | 5 | $1,600.30 |
| L6050 | Wrist disarticulation, molded socket, flexible elbow hinges | 22 | $1,619.80 |
| L6055 | Wrist disarticulation | 22 | $2,066.91 |
| L6100 | Below elbow, molded socket, flexible elbow hinge | 22 | $1,804.41 |
| L6110 | Below elbow, molded socket, | 22 | $1,927.60 |
| L6120 | Below elbow, molded double wall split socket | 22 | $2,289.70 |
| L6130 | Below elbow, molded double wall split socket | 22 | $2,413.90 |
| L6200 | Elbow disarticulation, molded socket, outside locking hinge | 22 | $2,253.00 |
| L6205 | Elbow disarticulation | 22 | $3,330.65 |
| L6250 | Above elbow, molded double wall socket | 22 | $2,353.03 |
| L6300 | Shoulder disarticulation, molded socket, shoulder bulkhead | 22 | $3,217.57 |
| L6310 | Shoulder disarticulation, passive restoration | 22 | $2,671.10 |
| L6320 | Shoulder disarticulation, passive restoration | 21 | $1,530.61 |
| L6350 | Interscapular thoracic, molded socket, shoulder bulkhead | 22 | $3,816.30 |
| L6360 | Interscapular thoracic, passive restoration | 22 | $2,849.19 |
| L6370 | Interscapular thoracic, passive restoration | 21 | $1,868.83 |
| L6380 | Immediate post surgical or early fitting | 21 | $1,153.80 |
| L6382 | Immediate post surgical or early fitting | 21 | $1,460.41 |
| L6384 | Immediate post surgical or early fitting | 21 | $1,875.23 |
| L6386 | Immediate post surgical or early fitting | 20 | $368.00 |
| L6388 | Immediate post surgical or early fitting | 21 | $419.46 |
| L6400 | Below elbow, molded socket, endoskeletal system | 22 | $2,166.60 |
| L6450 | Elbow disarticulation, molded socket, endoskeletal system | 22 | $2,674.66 |
| L6500 | Above elbow, molded socket, endoskeletal system | 22 | $2,806.62 |
| L6550 | Shoulder disarticulation, molded socket | 22 | $3,217.89 |
| L6570 | Interscapular thoracic, molded socket, endoskeletal system | 22 | $3,788.12 |
| L6580 | Preparatory, wrist disarticulation or below elbow | 20 | $1,433.62 |
| L6582 | Preparatory, wrist disarticulation or below elbow | 21 | $1,317.12 |
| L6584 | Preparatory, elbow disarticulation or above elbow | 20 | $1,843.61 |
| L6586 | Preparatory, elbow disarticulation or above elbow | 20 | $1,782.39 |
| L6588 | Preparatory, shoulder disarticulation or interscapular... | 20 | $2,663.57 |
| L6590 | Preparatory, shoulder disarticulation or interscapular... | 21 | $2,303.01 |
| L6600 | Upper extremity additions, polycentric hinge, pair | 22 | $185.18 |
| L6605 | Upper extremity additions, single pivot hinge, pair | 22 | $173.79 |
| L6610 | Upper extremity additions, flexible metal hinge, pair | 22 | $142.86 |
| L6611 | Addition to upper extremity prosthesis, external powered | 18 | $375.34 |
| L6615 | Upper extremity addition, disconnect locking wrist unit | 22 | $154.90 |
| L6616 | Upper extremity addition | 21 | $58.76 |
| L6620 | Upper extremity addition, flexion/extension wrist unit | 22 | $251.79 |
| L6621 | Upper extremity prosthesis addition | 16 | $2,068.99 |
| L6623 | Upper extremity addition | 21 | $649.18 |
| L6624 | Upper extremity addition | 18 | $3,406.64 |
| L6625 | Upper extremity addition | 22 | $474.88 |
| L6628 | Upper extremity addition, quick disconnect hook adapter | 21 | $454.43 |
| L6629 | Upper extremity addition | 21 | $135.00 |
| L6630 | Upper extremity addition, stainless steel, any wrist | 22 | $183.80 |
| L6632 | Upper extremity addition, latex suspension sleeve, each | 21 | $58.78 |
| L6635 | Upper extremity addition, lift assist for elbow | 22 | $173.51 |
| L6637 | Upper extremity addition, nudge control elbow lock | 21 | $314.68 |
| L6638 | Upper extremity addition to prosthesis | 17 | $2,258.85 |
| L6640 | Upper extremity additions, shoulder abduction joint, pair | 22 | $276.27 |
| L6641 | Upper extremity addition, excursion amplifier, pulley type | 21 | $158.01 |
| L6642 | Upper extremity addition, excursion amplifier, lever type | 21 | $213.70 |
| L6645 | Upper extremity addition, shoulder flexion-abduction joint | 22 | $298.31 |
| L6646 | Upper extremity addition, shoulder joint | 18 | $2,852.95 |
| L6647 | Upper extremity addition, shoulder lock mechanism | 19 | $470.33 |
| L6648 | Upper extremity addition, shoulder lock mechanism | 15 | $2,946.56 |
| L6650 | Upper extremity addition, shoulder universal joint, each | 22 | $314.55 |
| L6655 | Upper extremity addition, standard control cable, extra | 22 | $69.18 |
| L6660 | Upper extremity addition, heavy duty control cable | 22 | $78.59 |
| L6665 | Upper extremity addition, teflon, or equal, cable lining | 22 | $41.63 |
| L6670 | Upper extremity addition, hook to hand, cable adapter | 22 | $43.42 |
| L6672 | Upper extremity addition, harness, chest or shoulder | 22 | $168.03 |
| L6675 | Upper extremity addition, harness, (e.g. | 22 | $98.17 |
| L6676 | Upper extremity addition, harness, (e.g. | 22 | $113.75 |
| L6677 | Upper extremity addition, harness, triple control | 19 | $268.71 |
| L6680 | Upper extremity addition, test socket | 22 | $213.26 |
| L6682 | Upper extremity addition, test socket | 22 | $221.36 |
| L6684 | Upper extremity addition, test socket | 22 | $327.47 |
| L6686 | Upper extremity addition, suction socket | 22 | $558.79 |
| L6687 | Upper extremity addition, frame type socket | 22 | $512.43 |
| L6688 | Upper extremity addition, frame type socket | 22 | $461.39 |
| L6689 | Upper extremity addition, frame type socket | 21 | $689.27 |
| L6690 | Upper extremity addition, frame type socket | 22 | $667.75 |
| L6691 | Upper extremity addition, removable insert, each | 22 | $310.48 |
| L6692 | Upper extremity addition, silicone gel insert or equal | 22 | $490.41 |
| L6693 | Upper extremity addition, locking elbow | 21 | $2,536.49 |
| L6694 | Addition to upper extremity prosthesis | 21 | $662.95 |
| L6695 | Addition to upper extremity prosthesis | 20 | $562.80 |
| L6696 | Addition to upper extremity prosthesis | 20 | $1,199.17 |
| L6697 | Addition to upper extremity prosthesis | 18 | $1,219.82 |
| L6698 | Addition to upper extremity prosthesis, lock mechanism | 21 | $517.62 |
| L6700 | Upper extremity addition, external powered feature | 7 | $27,471.04 |
| L6703 | Terminal device, passive hand/mitt, any material, any size | 19 | $326.33 |
| L6704 | Terminal device, sport/recreational/work attachment | 17 | $604.84 |
| L6706 | Terminal device, hook, mechanical, voluntary opening | 20 | $344.18 |
| L6707 | Terminal device, hook, mechanical, voluntary closing | 20 | $1,233.78 |
| L6708 | Terminal device, hand, mechanical, voluntary opening | 19 | $804.87 |
| L6709 | Terminal device, hand, mechanical, voluntary closing | 19 | $1,180.90 |
| L6711 | Terminal device, hook, mechanical, voluntary opening | 18 | $608.13 |
| L6712 | Terminal device, hook, mechanical, voluntary closing | 17 | $1,118.12 |
| L6713 | Terminal device, hand, mechanical, voluntary opening | 17 | $1,421.50 |
| L6714 | Terminal device, hand, mechanical, voluntary closing | 17 | $1,204.01 |
| L6715 | Terminal device, multiple articulating digit | 8 | $3,247.36 |
| L6721 | Terminal device, hook or hand, heavy duty, mechanical | 19 | $2,130.47 |
| L6722 | Terminal device, hook or hand, heavy duty, mechanical | 19 | $1,844.85 |
| L6805 | Addition to terminal device, modifier wrist unit | 21 | $312.46 |
| L6810 | Addition to terminal device, precision pinch device | 22 | $170.45 |
| L6880 | Electric hand, switch or myoelectric controlled | 6 | $24,797.75 |
| L6881 | Automatic grasp feature | 17 | $3,728.72 |
| L6882 | Microprocessor control feature | 17 | $2,923.19 |
| L6883 | Replacement socket, below elbow/wrist disarticulation | 18 | $1,786.63 |
| L6884 | Replacement socket, above elbow/elbow disarticulation | 17 | $2,354.97 |
| L6885 | Replacement socket, shoulder disarticulation/interscapular... | 17 | $3,009.70 |
| L6890 | Addition to upper extremity prosthesis | 21 | $170.86 |
| L6895 | Addition to upper extremity prosthesis | 19 | $570.44 |
| L6900 | Hand restoration (casts, shading and measurements included) | 20 | $1,450.77 |
| L6905 | Hand restoration (casts, shading and measurements included) | 20 | $1,433.19 |
| L6910 | Hand restoration (casts, shading and measurements included) | 20 | $1,343.11 |
| L6915 | Hand restoration (shading, and measurements included) | 20 | $559.22 |
| L6920 | Wrist disarticulation, external power | 16 | $7,136.11 |
| L6925 | Wrist disarticulation, external power | 16 | $7,813.77 |
| L6930 | Below elbow, external power, self-suspended inner socket | 16 | $7,107.02 |
| L6935 | Below elbow, external power, self-suspended inner socket | 17 | $8,116.38 |
| L6940 | Elbow disarticulation, external power, molded inner socket | 16 | $8,938.88 |
| L6945 | Elbow disarticulation, external power, molded inner socket | 16 | $10,169.08 |
| L6950 | Above elbow, external power, molded inner socket | 16 | $9,452.70 |
| L6955 | Above elbow, external power, molded inner socket | 16 | $11,147.80 |
| L6960 | Shoulder disarticulation, external power | 16 | $11,818.18 |
| L6965 | Shoulder disarticulation, external power | 16 | $13,927.24 |
| L6970 | Interscapular-thoracic, external power, molded inner socket | 16 | $14,331.51 |
| L6975 | Interscapular-thoracic, external power, molded inner socket | 16 | $15,750.83 |
| L7007 | Electric hand, switch or myoelectric controlled, adult | 16 | $3,399.12 |
| L7008 | Electric hand, switch or myoelectric, controlled, pediatric | 17 | $5,653.82 |
| L7009 | Electric hook, switch or myoelectric controlled, adult | 17 | $3,471.76 |
| L7040 | Prehensile actuator, switch controlled | 17 | $2,771.41 |
| L7045 | Electric hook, switch or myoelectric controlled, pediatric | 17 | $1,487.21 |
| L7170 | Electronic elbow, hosmer or equal, switch controlled | 17 | $5,481.08 |
| L7180 | Electronic elbow, microprocessor sequential control of elbow... | 15 | $35,179.27 |
| L7181 | Electronic elbow, microprocessor simultaneous control of... | 13 | $37,769.02 |
| L7185 | Electronic elbow, adolescent, variety village or equal | 16 | $6,020.92 |
| L7186 | Electronic elbow, child, variety village or equal | 17 | $8,458.94 |
| L7190 | Electronic elbow, adolescent, variety village or equal | 15 | $7,650.61 |
| L7191 | Electronic elbow, child, variety village or equal | 16 | $9,295.74 |
| L7259 | Electronic wrist rotator, any type | 13 | $3,734.34 |
| L7360 | Six volt battery, each | 17 | $249.15 |
| L7362 | Battery charger, six volt, each | 17 | $264.15 |
| L7364 | Twelve volt battery, each | 16 | $477.66 |
| L7366 | Battery charger, twelve volt, each | 16 | $624.59 |
| L7367 | Lithium ion battery, rechargeable, replacement | 16 | $359.33 |
| L7368 | Lithium ion battery charger, replacement only | 17 | $457.16 |
| L7400 | Addition to upper extremity prosthesis | 21 | $279.27 |
| L7401 | Addition to upper extremity prosthesis | 18 | $311.71 |
| L7402 | Addition to upper extremity prosthesis | 18 | $337.79 |
| L7403 | Addition to upper extremity prosthesis | 20 | $335.73 |
| L7404 | Addition to upper extremity prosthesis | 19 | $506.49 |
| L7405 | Addition to upper extremity prosthesis | 18 | $662.67 |
| L7406 | Addition to upper extremity prosthesis, user adjustable | 8 | $2,917.70 |
| L7510 | Repair of prosthetic device, repair or replace minor parts | 10 | $38.91 |
| L7520 | Repair prosthetic device, labor component, per 15 minutes | 17 | $21.73 |
| L7700 | Gasket or seal, for use with prosthetic socket insert | 16 | $127.13 |
| L8000 | Breast prosthesis, mastectomy bra | 22 | $32.64 |
| L8001 | Breast prosthesis, mastectomy bra | 20 | $114.88 |
| L8002 | Breast prosthesis, mastectomy bra | 20 | $151.10 |
| L8010 | Breast prosthesis, mastectomy sleeve | 10 | $43.82 |
| L8015 | External breast prosthesis garment, with mastectomy form | 20 | $54.45 |
| L8020 | Breast prosthesis, mastectomy form | 22 | $185.18 |
| L8030 | Breast prosthesis, silicone or equal | 22 | $292.93 |
| L8031 | Breast prosthesis, silicone or equal | 14 | $311.69 |
| L8032 | Nipple prosthesis, prefabricated, reusable, any type, each | 11 | $38.35 |
| L8035 | Custom breast prosthesis, post mastectomy | 15 | $3,474.16 |
| L8040 | Nasal prosthesis, provided by a non-physician | 10 | $2,370.67 |
| L8041 | Midfacial prosthesis, provided by a non-physician | 11 | $2,840.80 |
| L8042 | Orbital prosthesis, provided by a non-physician | 11 | $3,191.86 |
| L8043 | Upper facial prosthesis, provided by a non-physician | 11 | $3,574.89 |
| L8044 | Hemi-facial prosthesis, provided by a non-physician | 11 | $3,957.90 |
| L8045 | Auricular prosthesis, provided by a non-physician | 10 | $2,644.94 |
| L8046 | Partial facial prosthesis, provided by a non-physician | 10 | $2,479.04 |
| L8047 | Nasal septal prosthesis, provided by a non-physician | 11 | $1,308.66 |
| L8049 | Repair or modification of maxillofacial prosthesis | 6 | $20.94 |
| L8300 | Truss, single with standard pad | 21 | $76.31 |
| L8310 | Truss, double with standard pads | 21 | $130.41 |
| L8320 | Truss, addition to standard pad, water pad | 20 | $48.62 |
| L8330 | Truss, addition to standard pad, scrotal pad | 20 | $44.59 |
| L8400 | Prosthetic sheath, below knee, each | 21 | $14.26 |
| L8410 | Prosthetic sheath, above knee, each | 21 | $18.18 |
| L8415 | Prosthetic sheath, upper limb, each | 22 | $18.99 |
| L8417 | Prosthetic sheath/sock, including a gel cushion layer | 20 | $63.71 |
| L8420 | Prosthetic sock, multiple ply, below knee, each | 21 | $17.00 |
| L8430 | Prosthetic sock, multiple ply, above knee, each | 21 | $21.09 |
| L8435 | Prosthetic sock, multiple ply, upper limb, each | 22 | $18.25 |
| L8440 | Prosthetic shrinker, below knee, each | 22 | $35.11 |
| L8460 | Prosthetic shrinker, above knee, each | 21 | $57.11 |
| L8465 | Prosthetic shrinker, upper limb, each | 22 | $42.45 |
| L8470 | Prosthetic sock, single ply, fitting, below knee, each | 21 | $5.72 |
| L8480 | Prosthetic sock, single ply, fitting, above knee, each | 21 | $7.89 |
| L8485 | Prosthetic sock, single ply, fitting, upper limb, each | 21 | $9.57 |
| L8500 | Artificial larynx, any type | 20 | $609.84 |
| L8501 | Tracheostomy speaking valve | 21 | $108.96 |
| L8507 | Tracheo-esophageal voice prosthesis, patient inserted | 14 | $39.82 |
| L8509 | Tracheo-esophageal voice prosthesis | 15 | $102.93 |
| L8510 | Voice amplifier | 13 | $238.19 |
| L8511 | Insert for indwelling tracheoesophageal prosthesis | 13 | $69.87 |
| L8512 | Gelatin capsules or equivalent | 10 | $2.10 |
| L8513 | Cleaning device used with tracheoesophageal voice... | 11 | $5.02 |
| L8514 | Tracheoesophageal puncture dilator, replacement only, each | 11 | $90.60 |
| L8515 | Gelatin capsule, application device for use with... | 12 | $60.06 |
| L8600 | Implantable breast prosthesis, silicone or equal | 7 | $700.26 |
| L8603 | Injectable bulking agent, collagen implant, urinary tract | 12 | $418.37 |
| L8605 | Injectable bulking agent | 8 | $585.48 |
| L8606 | Injectable bulking agent, synthetic implant, urinary tract | 11 | $208.51 |
| L8607 | Injectable bulking agent for vocal cord medialization | 7 | $40.42 |
| L8609 | Artificial cornea | 6 | $6,351.06 |
| L8610 | Ocular implant | 8 | $618.66 |
| L8612 | Aqueous shunt | 8 | $683.77 |
| L8613 | Ossicula implant | 7 | $292.68 |
| L8614 | Cochlear device, includes all internal and external... | 12 | $18,202.90 |
| L8615 | Headset/headpiece for use with cochlear implant device | 20 | $372.59 |
| L8616 | Microphone for use with cochlear implant device, replacement | 20 | $91.77 |
| L8617 | Transmitting coil for use with cochlear implant device | 20 | $79.62 |
| L8618 | Transmitter cable for use with cochlear implant device or... | 20 | $23.22 |
| L8619 | Cochlear implant, external speech processor and controller | 19 | $7,259.54 |
| L8621 | Zinc air battery for use with cochlear implant device and... | 18 | $0.5577 |
| L8622 | Alkaline battery for use with cochlear implant device | 18 | $0.29 |
| L8623 | Lithium ion battery for use with cochlear implant device... | 18 | $53.83 |
| L8624 | Lithium ion battery for use with cochlear implant or... | 18 | $139.03 |
| L8625 | External recharging system for battery for use with cochlear... | 13 | $184.65 |
| L8627 | Cochlear implant, external speech processor, component | 17 | $6,366.34 |
| L8628 | Cochlear implant, external controller component, replacement | 17 | $1,130.05 |
| L8629 | Transmitting coil and cable, integrated | 17 | $162.27 |
| L8630 | Metacarpophalangeal joint implant | 6 | $382.02 |
| L8631 | Metacarpal phalangeal joint replacement, two or more pieces | 7 | $2,217.72 |
| L8641 | Metatarsal joint implant | 7 | $420.15 |
| L8642 | Hallux implant | 7 | $340.13 |
| L8658 | Interphalangeal joint spacer, silicone or equal, each | 7 | $366.32 |
| L8659 | Interphalangeal finger joint replacement, 2 or more pieces | 6 | $1,957.16 |
| L8670 | Vascular graft material, synthetic, implant | 5 | $570.96 |
| L8678 | Electrical stimulator supplies | 7 | $12.25 |
| L8679 | Implantable neurostimulator, pulse generator, any type | 9 | $8,691.00 |
| L8680 | Implantable neurostimulator electrode, each | 6 | $329.06 |
| L8681 | Patient programmer (external) for use with implantable... | 8 | $1,122.27 |
| L8682 | Implantable neurostimulator radiofrequency receiver | 8 | $6,018.63 |
| L8683 | Radiofrequency transmitter | 8 | $5,502.64 |
| L8684 | Radiofrequency transmitter | 9 | $807.86 |
| L8685 | Implantable neurostimulator pulse generator, single array | 6 | $11,946.78 |
| L8686 | Implantable neurostimulator pulse generator, single array | 6 | $7,854.98 |
| L8687 | Implantable neurostimulator pulse generator, dual array | 6 | $14,788.16 |
| L8688 | Implantable neurostimulator pulse generator, dual array | 6 | $9,854.45 |
| L8689 | External recharging system for battery | 8 | $1,594.24 |
| L8690 | Auditory osseointegrated device | 9 | $4,484.22 |
| L8691 | Auditory osseointegrated device, external sound processor | 19 | $1,884.95 |
| L8692 | Auditory osseointegrated device, external sound processor | 12 | $2,571.36 |
| L8693 | Auditory osseointegrated device abutment, any length | 13 | $1,429.32 |
| L8694 | Auditory osseointegrated device, transducer/actuator | 18 | $906.74 |
| L8695 | External recharging system for battery | 7 | $15.68 |
| L8696 | Antenna (external) for use with implantable... | 6 | $211.27 |
| L8701 | Powered upper extremity range of motion assist device | 5 | $29,724.61 |
| L8702 | Powered upper extremity range of motion assist device | 5 | $58,481.45 |
| Q0477 | Power module patient cable for use with electric or... | 8 | $724.18 |
| Q0480 | Driver for use with pneumatic ventricular assist device | 8 | $89,999.95 |
| Q0481 | Microprocessor control unit for use with electric... | 8 | $15,580.43 |
| Q0482 | Microprocessor control unit for use with electric/pneumatic... | 8 | $4,880.08 |
| Q0483 | Monitor/display module for use with electric ventricular... | 8 | $20,103.79 |
| Q0484 | Monitor/display module for use with electric or... | 8 | $3,904.10 |
| Q0485 | Monitor control cable for use with electric ventricular... | 8 | $376.91 |
| Q0486 | Monitor control cable for use with electric/pneumatic... | 8 | $313.73 |
| Q0487 | Leads (pneumatic/electrical) for use with any type... | 8 | $366.01 |
| Q0489 | Power pack base for use with electric/pneumatic ventricular... | 8 | $17,428.88 |
| Q0490 | Emergency power source for use with electric ventricular... | 8 | $753.90 |
| Q0491 | Emergency power source for use with electric/pneumatic... | 8 | $1,185.21 |
| Q0492 | Emergency power supply cable for use with electric... | 8 | $95.47 |
| Q0493 | Emergency power supply cable for use with electric/pneumatic... | 8 | $271.90 |
| Q0494 | Emergency hand pump for use with electric or... | 8 | $230.09 |
| Q0495 | Battery/power pack charger for use with electric or... | 8 | $4,478.77 |
| Q0496 | Battery, other than lithium-ion | 9 | $1,413.19 |
| Q0497 | Battery clips for use with electric or electric/pneumatic... | 8 | $501.96 |
| Q0498 | Holster for use with electric or electric/pneumatic... | 8 | $550.78 |
| Q0499 | Belt/vest/bag for use to carry external peripheral... | 8 | $178.95 |
| Q0500 | Filters for use with electric or electric/pneumatic... | 8 | $36.78 |
| Q0501 | Shower cover for use with electric or electric/pneumatic... | 8 | $547.56 |
| Q0502 | Mobility cart for pneumatic ventricular assist device | 8 | $697.12 |
| Q0503 | Battery for pneumatic ventricular assist device | 8 | $1,394.30 |
| Q0504 | Power adapter for pneumatic ventricular assist device | 8 | $735.74 |
| Q4001 | Casting supplies, body cast adult, with or without head | 10 | $43.41 |
| Q4002 | Cast supplies, body cast adult, with or without head | 10 | $134.93 |
| Q4003 | Cast supplies, shoulder cast, adult (11 years +), plaster | 10 | $31.18 |
| Q4004 | Cast supplies, shoulder cast, adult (11 years +), fiberglass | 10 | $98.41 |
| Q4005 | Cast supplies, long arm cast, adult (11 years +), plaster | 10 | $11.49 |
| Q4006 | Cast supplies, long arm cast, adult (11 years +), fiberglass | 10 | $25.90 |
| Q4007 | Cast supplies, long arm cast, pediatric (0-10 years) | 10 | $5.75 |
| Q4008 | Cast supplies, long arm cast, pediatric (0-10 years) | 10 | $12.95 |
| Q4009 | Cast supplies, short arm cast, adult (11 years +), plaster | 10 | $7.68 |
| Q4010 | Cast supplies, short arm cast, adult (11 years +) | 11 | $20.03 |
| Q4012 | Cast supplies, short arm cast, pediatric (0-10 years) | 10 | $8.65 |
| Q4013 | Cast supplies, gauntlet cast | 10 | $13.97 |
| Q4014 | Cast supplies, gauntlet cast | 10 | $23.56 |
| Q4015 | Cast supplies, gauntlet cast | 10 | $6.99 |
| Q4016 | Cast supplies, gauntlet cast | 10 | $11.78 |
| Q4017 | Cast supplies, long arm splint, adult (11 years +), plaster | 10 | $8.08 |
| Q4018 | Cast supplies, long arm splint, adult (11 years +) | 10 | $12.87 |
| Q4019 | Cast supplies, long arm splint, pediatric (0-10 years) | 10 | $4.04 |
| Q4020 | Cast supplies, long arm splint, pediatric (0-10 years) | 10 | $6.46 |
| Q4021 | Cast supplies, short arm splint, adult (11 years +), plaster | 10 | $5.98 |
| Q4022 | Cast supplies, short arm splint, adult (11 years +) | 11 | $12.51 |
| Q4023 | Cast supplies, short arm splint, pediatric (0-10 years) | 10 | $3.01 |
| Q4024 | Cast supplies, short arm splint, pediatric (0-10 years) | 10 | $5.40 |
| Q4025 | Cast supplies, hip spica (one or both legs), adult | 10 | $33.51 |
| Q4026 | Cast supplies, hip spica (one or both legs), adult | 10 | $97.05 |
| Q4027 | Cast supplies, hip spica (one or both legs), pediatric | 10 | $16.77 |
| Q4028 | Cast supplies, hip spica (one or both legs), pediatric | 10 | $52.35 |
| Q4029 | Cast supplies, long leg cast, adult (11 years +), plaster | 10 | $26.90 |
| Q4030 | Cast supplies, long leg cast, adult (11 years +), fiberglass | 10 | $70.78 |
| Q4031 | Cast supplies, long leg cast, pediatric (0-10 years) | 10 | $13.43 |
| Q4032 | Cast supplies, long leg cast, pediatric (0-10 years) | 10 | $35.39 |
| Q4033 | Cast supplies, long leg cylinder cast, adult (11 years +) | 10 | $25.09 |
| Q4034 | Cast supplies, long leg cylinder cast, adult (11 years +) | 10 | $62.36 |
| Q4035 | Cast supplies, long leg cylinder cast, pediatric | 10 | $12.54 |
| Q4036 | Cast supplies, long leg cylinder cast, pediatric | 10 | $31.21 |
| Q4037 | Cast supplies, short leg cast, adult (11 years +), plaster | 10 | $15.28 |
| Q4038 | Cast supplies, short leg cast, adult (11 years +) | 11 | $42.37 |
| Q4039 | Cast supplies, short leg cast, pediatric (0-10 years) | 10 | $7.68 |
| Q4040 | Cast supplies, short leg cast, pediatric (0-10 years) | 10 | $19.16 |
| Q4041 | Cast supplies, long leg splint, adult (11 years +), plaster | 10 | $17.74 |
| Q4042 | Cast supplies, long leg splint, adult (11 years +) | 10 | $30.28 |
| Q4043 | Cast supplies, long leg splint, pediatric (0-10 years) | 10 | $8.87 |
| Q4044 | Cast supplies, long leg splint, pediatric (0-10 years) | 10 | $15.16 |
| Q4045 | Cast supplies, short leg splint, adult (11 years +), plaster | 11 | $11.93 |
| Q4046 | Cast supplies, short leg splint, adult (11 years +) | 10 | $17.37 |
| Q4047 | Cast supplies, short leg splint, pediatric (0-10 years) | 10 | $5.38 |
| Q4048 | Cast supplies, short leg splint, pediatric (0-10 years) | 10 | $8.70 |
| Q4049 | Finger splint, static | 10 | $2.15 |
| S1015 | Iv tubing extension set | 6 | $5.85 |
| S1040 | Cranial remolding orthosis, pediatric, rigid | 17 | $2,066.40 |
| S5521 | Home infusion therapy, all supplies | 5 | $110.23 |
| S8101 | Holding chamber or spacer for use with an inhaler or... | 5 | $28.03 |
| S8210 | Mucus trap | 5 | $2.25 |
| S8265 | Haberman feeder for cleft lip/palate | 10 | $19.28 |
| S8415 | Supplies for home delivery of infant | 6 | $345.13 |
| S8421 | Gradient pressure aid (sleeve and glove combination) | 7 | $73.68 |
| S8424 | Gradient pressure aid (sleeve), ready made | 8 | $48.26 |
| S8427 | Gradient pressure aid (glove), ready made | 8 | $72.38 |
| S8428 | Gradient pressure aid (gauntlet), ready made | 8 | $35.91 |
| S8490 | Insulin syringes (100 syringes, any size) | 7 | $26.38 |
| S8999 | Medical supplies | 11 | $93.22 |
| T2101 | Human breast milk processing, storage and distribution only | 7 | $4.50 |
| T4521 | Adult sized disposable incontinence product, brief/diaper | 20 | $0.615 |
| T4522 | Adult sized disposable incontinence product, brief/diaper | 20 | $0.63 |
| T4523 | Adult sized disposable incontinence product, brief/diaper | 19 | $0.72 |
| T4524 | Adult sized disposable incontinence product, brief/diaper | 19 | $0.86 |
| T4525 | Adult sized disposable incontinence product | 18 | $0.715 |
| T4526 | Adult sized disposable incontinence product | 18 | $0.75 |
| T4527 | Adult sized disposable incontinence product | 18 | $0.805 |
| T4528 | Adult sized disposable incontinence product | 18 | $0.92 |
| T4529 | Pediatric sized disposable incontinence product | 20 | $0.52 |
| T4530 | Pediatric sized disposable incontinence product | 19 | $0.55 |
| T4531 | Pediatric sized disposable incontinence product | 19 | $0.67 |
| T4532 | Pediatric sized disposable incontinence product | 19 | $0.80 |
| T4533 | Youth sized disposable incontinence product, brief/diaper | 19 | $0.61 |
| T4534 | Youth sized disposable incontinence product | 18 | $0.815 |
| T4535 | Disposable liner/shield/guard/pad/undergarment | 17 | $0.37 |
| T4536 | Incontinence product, protective underwear/pull-on | 9 | $7.69 |
| T4537 | Incontinence product, protective underpad, reusable | 10 | $12.97 |
| T4539 | Incontinence product, diaper/brief, reusable, any size, each | 7 | $6.90 |
| T4540 | Incontinence product, protective underpad, reusable | 7 | $10.00 |
| T4541 | Incontinence product, disposable underpad, large, each | 12 | $0.485 |
| T4542 | Incontinence product, disposable underpad, small size, each | 9 | $0.40 |
| T4543 | Adult sized disposable incontinence product | 17 | $1.59 |
| T4544 | Adult sized disposable incontinence product | 16 | $1.42 |
Equipment & supplies rates in your statesRates, managed-care rules, Medicare comparison and changes, for the codes you bill.